Provider Demographics
NPI:1013179001
Name:JOHNSON, JUSTIN DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE C-215
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-258-6450
Mailing Address - Fax:859-258-6499
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE C-215
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-258-6450
Practice Address - Fax:859-258-6499
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE5815208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5815OtherTEP
NE5815OtherTEP