Provider Demographics
NPI:1043393838
Name:JOHNSON, DERREK (DC)
Entity Type:Individual
Prefix:DR
First Name:DERREK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-0379
Mailing Address - Country:US
Mailing Address - Phone:218-963-3311
Mailing Address - Fax:218-963-3313
Practice Address - Street 1:5482 COUNTY ROAD 18
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468
Practice Address - Country:US
Practice Address - Phone:218-963-3311
Practice Address - Fax:218-963-3313
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC4116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU95595Medicare UPIN