1003810862 NPI number — CAMRON L JOHNSON PRIVITERA D.O.

Table of content: CAMRON L JOHNSON PRIVITERA D.O. (NPI 1003810862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003810862 NPI number — CAMRON L JOHNSON PRIVITERA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON PRIVITERA
Provider First Name:
CAMRON
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1003810862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 HIGHLAND AVE SE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24013-2218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-344-9213
Provider Business Mailing Address Fax Number:
540-345-7559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 HIGHLAND AVE SE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24013-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-344-9213
Provider Business Practice Location Address Fax Number:
540-345-7559
Provider Enumeration Date:
06/09/2005

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: 208000000X , with the licence number:  0102201592 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6830577 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 244013 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54088505618 . This is a "JOHN DEERE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010072701 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 139824 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7861556 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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