Provider Demographics
NPI:1003166430
Name:JOHNSON, RODRICK D
Entity Type:Individual
Prefix:
First Name:RODRICK
Middle Name:D
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 1:1941 S 42ND ST
Mailing Address - Street 2:STE 514
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-2939
Mailing Address - Country:US
Mailing Address - Phone:402-614-8444
Mailing Address - Fax:402-614-8443
Practice Address - Street 1:1941 S 42ND ST
Practice Address - Street 2:STE 514
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2939
Practice Address - Country:US
Practice Address - Phone:402-614-8444
Practice Address - Fax:402-614-8443
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker