Provider Demographics
NPI:1265491849
Name:JOHNSON, DONALD BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:BRUCE
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 1:1815 1ST AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5417
Mailing Address - Country:US
Mailing Address - Phone:319-363-0474
Mailing Address - Fax:319-363-2170
Practice Address - Street 1:1815 1ST AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5417
Practice Address - Country:US
Practice Address - Phone:319-363-0474
Practice Address - Fax:319-363-2170
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD20628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0169631Medicaid
IAA01560Medicare UPIN
IA16963Medicare ID - Type Unspecified