Provider Demographics
NPI:1538195615
Name:JOHNSON, ROBERT JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9304
Mailing Address - Country:US
Mailing Address - Phone:315-782-1650
Mailing Address - Fax:315-788-8547
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9304
Practice Address - Country:US
Practice Address - Phone:315-782-1650
Practice Address - Fax:315-788-8547
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226827208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02361237Medicaid
RB4668Medicare PIN
NY02361237Medicaid