Provider Demographics
NPI:1063579779
Name:JOHNSON, SPENCER FRY (MD)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:FRY
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 1:11703 AMER CT
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5953
Mailing Address - Country:US
Mailing Address - Phone:301-282-8751
Mailing Address - Fax:
Practice Address - Street 1:4400 STAMP RD
Practice Address - Street 2:SUITE 314
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-6716
Practice Address - Country:US
Practice Address - Phone:301-702-0047
Practice Address - Fax:301-702-0841
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC172322084P0800X
MDD0516452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD186100000Medicaid
DC011032300Medicaid
DC011032300Medicaid
MDE74090Medicare UPIN
MD186100000Medicaid