Basic Information
| Provider Information | |||||||||
| NPI: | 1386610319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | STE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453357 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BRANCH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077406303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322225200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 25MB07617400 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 25MB07617400 | NJ | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | 25MB07617400 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BJ8483339 | 01 | NJ | DEA | OTHER | 25MB07617400 | 01 | NJ | LICENCE | OTHER | 0146960 | 05 | NJ | MEDICAID | BJ8483339 | 01 | PA | DEA NUMBER | OTHER |