Provider Demographics
NPI:1053798959
Name:JOHNSON, JONATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 EMPIRE BLVD # 221
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-1934
Mailing Address - Country:US
Mailing Address - Phone:585-723-7191
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289321207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology