Provider Demographics
NPI:1003816471
Name:JOHNSON, DOUGLAS W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 WILLOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45430-1552
Mailing Address - Country:US
Mailing Address - Phone:937-429-7132
Mailing Address - Fax:937-224-5307
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:4TH FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1445
Practice Address - Country:US
Practice Address - Phone:937-221-7001
Practice Address - Fax:937-224-5307
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0344363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJOPA17301Medicare ID - Type Unspecified