Provider Demographics
NPI:1427141357
Name:JOHNSON, DONALD (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DRIVE
Mailing Address - Street 2:SUITE 1210
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4499
Mailing Address - Country:US
Mailing Address - Phone:317-839-9833
Mailing Address - Fax:317-839-7549
Practice Address - Street 1:1100 SOUTHFIELD DRIVE
Practice Address - Street 2:SUITE 1210
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-4499
Practice Address - Country:US
Practice Address - Phone:317-839-9833
Practice Address - Fax:317-839-7549
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100353460Medicaid
080158687Medicare PIN
IN151560A2Medicare PIN
IN100353460Medicaid
IN152380AMedicare PIN