Provider Demographics
NPI:1164289245
Name:JOHNSON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5814 W 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1958
Mailing Address - Country:US
Mailing Address - Phone:317-444-0158
Mailing Address - Fax:
Practice Address - Street 1:5814 W 46TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1958
Practice Address - Country:US
Practice Address - Phone:317-444-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker