Provider Demographics
NPI:1285931923
Name:JOHNSON, GARY DAVID (DC, DCBCN)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC, DCBCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W. MORGAN STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-343-3412
Mailing Address - Fax:218-724-7826
Practice Address - Street 1:413 W MORGAN ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4432
Practice Address - Country:US
Practice Address - Phone:218-343-3412
Practice Address - Fax:218-724-7826
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1651111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition