Provider Demographics
NPI:1427337849
Name:DARRYL C JOHNSON DO PC
Entity type:Organization
Organization Name:DARRYL C JOHNSON DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-355-7770
Mailing Address - Street 1:1912 MIDDLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7600
Mailing Address - Country:US
Mailing Address - Phone:563-355-7770
Mailing Address - Fax:563-355-7997
Practice Address - Street 1:1912 MIDDLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7600
Practice Address - Country:US
Practice Address - Phone:563-355-7770
Practice Address - Fax:563-355-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02790207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4097246Medicaid