Provider Demographics
NPI:1932463445
Name:JOHNSON, AMY W (DO)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:WIRTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 W 10TH ST
Practice Address - Street 2:OPW M200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-656-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004606A207R00000X, 207RH0002X
IN11016694A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001083932OtherANTHEM PTAN
IN000001103600OtherANTHEM PTAN
IN201102260Medicaid
IN000001104167OtherANTHEM PTAN