Provider Demographics
NPI:1053507178
Name:JOHNSON, MARC I (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:I
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 1:47 RECKLESS PL
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1750
Mailing Address - Country:US
Mailing Address - Phone:732-842-5246
Mailing Address - Fax:732-842-5246
Practice Address - Street 1:47 RECKLESS PL
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1750
Practice Address - Country:US
Practice Address - Phone:732-842-5246
Practice Address - Fax:732-842-5246
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00202500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
162407Medicare PIN