Provider Demographics
NPI:1235832882
Name:JOHNSON, DARRYL MICHAEL
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:MICHAEL
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 1:1600 MARYLAND AVE NE APT 348
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-7664
Mailing Address - Country:US
Mailing Address - Phone:202-758-9328
Mailing Address - Fax:
Practice Address - Street 1:3029 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2506
Practice Address - Country:US
Practice Address - Phone:202-914-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCPRS0156175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist