Provider Demographics
NPI:1679573745
Name:JOHNSON, LYDIA JONES (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:JONES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MATTIE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:5201 HICKORY PARK DR STE A
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-2623
Practice Address - Country:US
Practice Address - Phone:804-262-6060
Practice Address - Fax:804-262-6422
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230897207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005901952Medicaid
7214219OtherAETNA
070015801OtherRAILROAD MEDICARE
147156OtherSOUTHERN HEALTH
217925OtherANTHEM
0300353OtherUNITED HEALTHCARE
VA070000330Medicare ID - Type Unspecified
VA005901952Medicaid