Provider Demographics
NPI:1801472360
Name:JOHNSON, MARIAH ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:ELIZABETH
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BLVD STE 601
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-355-7874
Mailing Address - Fax:704-355-5619
Practice Address - Street 1:1000 BLYTHE BLVD STE 601
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-7874
Practice Address - Fax:704-355-5619
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC302731390200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program