Provider Demographics
NPI:1225147127
Name:JOHNSON, DUKE J (MD)
Entity Type:Individual
Prefix:DR
First Name:DUKE
Middle Name:J
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 1:15233 W PAULINE TRL
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8429
Mailing Address - Country:US
Mailing Address - Phone:208-651-1182
Mailing Address - Fax:
Practice Address - Street 1:5600 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2007
Practice Address - Country:US
Practice Address - Phone:208-651-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-74272083P0901X, 207Q00000X
CAG550132083P0901X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE02763Medicare UPIN