Provider Demographics
NPI:1114966264
Name:JOHNSON, PETER JAMES (DPM)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OAK ST
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-2110
Mailing Address - Country:US
Mailing Address - Phone:570-249-1021
Mailing Address - Fax:
Practice Address - Street 1:107 W CENTRE ST
Practice Address - Street 2:
Practice Address - City:MAHANOY CITY
Practice Address - State:PA
Practice Address - Zip Code:17948-2605
Practice Address - Country:US
Practice Address - Phone:570-449-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005660213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASC005660OtherMEDICAL LICENSE PA
PABJ8532409OtherDEA
PABJ8532409OtherDEA