Provider Demographics
NPI:1043253867
Name:JOHNSON, WALLACE R (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:R
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8040
Mailing Address - Fax:443-462-3514
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1590
Practice Address - Country:US
Practice Address - Phone:410-328-7877
Practice Address - Fax:410-328-1048
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38086207RH0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD532101800Medicaid
MD424303-01OtherBLUE CROSS/BLUE SHIELD
MD424303-01OtherBLUE CROSS/BLUE SHIELD
MD110151073Medicare PIN
MD532101800Medicaid
MD044SMedicare PIN