Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 25MA02744100 | NJ |
N | 2080A0000X | Adolescent Medicine | 118888-1 | NY |
Y | 2080A0000X | Adolescent Medicine | 25MA02744100 | NJ |
NPI | 1134149230 |
---|---|
Provider Name | Robert Johnson |
First Address | Newark, NJ 07107-3000 |
Second Address | Newark, NJ 07103-2425 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2006 |
Last Update Date | 24/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03824935 | (05) | NY |
0853909 | (05) | NJ |