Provider Demographics
NPI:1285851659
Name:JOHNSON, JOHN G (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SWEDES RUN DR
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-2116
Mailing Address - Country:US
Mailing Address - Phone:856-829-0015
Mailing Address - Fax:856-829-0043
Practice Address - Street 1:2200 WALLACE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-2578
Practice Address - Country:US
Practice Address - Phone:856-829-0015
Practice Address - Fax:856-829-0043
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ078559WAOMedicare PIN