Provider Demographics
NPI:1043293244
Name:JOHNSON, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 RELIABLE PKWY
Mailing Address - Street 2:ST VINCENT EMERGENCY PHYSICIANS, INC
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0046
Mailing Address - Country:US
Mailing Address - Phone:317-802-3140
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:2001 W 86TH ST.
Practice Address - Street 2:ST. VINCENT EMERGENCY PHYSICIANS, INC
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-802-3140
Practice Address - Fax:317-870-0499
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037139A207Q00000X
IN01037139207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200013750Medicaid
IN200013730Medicaid
IN037870SMedicare ID - Type UnspecifiedMCARE #
INE32489Medicare UPIN
IN200013750Medicaid
IN037870SMedicare PIN
IN200013730Medicaid