Provider Demographics
NPI:1063424802
Name:JOHNSON, EVAN (DPT)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST PH 11-102
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-4878
Mailing Address - Fax:646-317-2902
Practice Address - Street 1:590 5TH AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4702
Practice Address - Country:US
Practice Address - Phone:212-305-4878
Practice Address - Fax:646-317-2902
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QAO673200225100000X
NY016746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133116525Medicare UPIN
NYW18711Medicare ID - Type UnspecifiedGROUP MEDICARE