Provider Demographics
NPI:1275619314
Name:JOHNSON, DANA D (DO)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:2150 HIGHWAY 54 S
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7330
Practice Address - Country:US
Practice Address - Phone:575-443-8133
Practice Address - Fax:575-443-8055
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.126547207Q00000X
NMA138006207Q00000X
NMA-1896-15207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88225038Medicaid
346703104Medicare PIN
NM88225038Medicaid