Provider Demographics
NPI:1114928652
Name:JOHNSON, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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 1:100 MADISON AVE
Mailing Address - Street 2:MID ATLANTIC SURGICAL ASSOC
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-6136
Mailing Address - Country:US
Mailing Address - Phone:973-971-7300
Mailing Address - Fax:973-984-7019
Practice Address - Street 1:1944 ROUTE 33
Practice Address - Street 2:SUITE 201
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4862
Practice Address - Country:US
Practice Address - Phone:732-776-4622
Practice Address - Fax:732-776-3765
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ62117208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5650909Medicaid
NJ5650909Medicaid
721716Medicare ID - Type Unspecified