Provider Demographics
NPI:1174700413
Name:JOHNSON, TAMARA EVETTE
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:EVETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
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 79586
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-3100
Mailing Address - Country:US
Mailing Address - Phone:301-567-1678
Mailing Address - Fax:301-567-2728
Practice Address - Street 1:6196 OXON HILL RD
Practice Address - Street 2:SUITE 430
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3100
Practice Address - Country:US
Practice Address - Phone:301-567-1678
Practice Address - Fax:301-567-2728
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20141208100000X
VA2305202035208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation