1285153395 NPI number — DR. CARLY JOHNSON AU.D.

Table of content: DR. CARLY JOHNSON AU.D. (NPI 1285153395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285153395 NPI number — DR. CARLY JOHNSON AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CARLY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285153395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 BROADWAY FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06473-2363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-234-1324
Provider Business Mailing Address Fax Number:
855-476-0993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 PRINCE ST STE 601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-752-1726
Provider Business Practice Location Address Fax Number:
855-451-0554
Provider Enumeration Date:
09/11/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  000672 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000672 . This is a "CT LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 15400058 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".