Provider Demographics
NPI:1588430342
Name:JOHNSON, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JOHNSON
Suffix:
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 1:3080 SOUTHDALE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1121
Mailing Address - Country:US
Mailing Address - Phone:937-815-3064
Mailing Address - Fax:
Practice Address - Street 1:3080 SOUTHDALE DR APT 3
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409-1121
Practice Address - Country:US
Practice Address - Phone:937-815-3064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver