Provider Demographics
NPI:1447363312
Name:JOHNSON, VINCENT GREGORY (DO)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:GREGORY
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:PO BOX 10668
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5668
Mailing Address - Country:US
Mailing Address - Phone:866-987-3990
Mailing Address - Fax:877-308-9097
Practice Address - Street 1:500 W MAIN ST STE 116
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3032
Practice Address - Country:US
Practice Address - Phone:631-422-6166
Practice Address - Fax:631-622-6266
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100207207LP2900X
NY291245207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243881604Medicaid
MO18469031OtherBCBS OF KANSAS CITY
KS200007670BMedicaid
MO18469031OtherBCBS OF KANSAS CITY
MO4953339Medicare ID - Type Unspecified
KS200007670BMedicaid