Provider Demographics
NPI:1235131848
Name:JOHNSON, DAVID GRANT (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GRANT
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-589-3100
Mailing Address - Fax:740-589-3123
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-589-3123
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.057127207Q00000X, 207P00000X
WV12479207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00806992OtherRAILROAD MEDICARE
OH000000277616OtherOHIO MEDICAID UNISON
OH0597813Medicaid
WV0049793000Medicaid
OH0597813OtherOHIO MEDICAID MOLINA
WV7395271Medicare PIN
OHA72721Medicare UPIN
WV0049793000Medicaid