Provider Demographics
NPI:1306156930
Name:JOHNSON, GARY ANTHONY II
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 DIGHTON CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8624
Mailing Address - Country:US
Mailing Address - Phone:757-202-6880
Mailing Address - Fax:757-963-9092
Practice Address - Street 1:1430 DIGHTON CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8624
Practice Address - Country:US
Practice Address - Phone:757-202-6880
Practice Address - Fax:757-963-9092
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-17
Last Update Date:2010-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT67226422347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle