Provider Demographics
NPI:1316005960
Name:JOHANSSON, JOHN RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:JOHANSSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3235
Mailing Address - Country:US
Mailing Address - Phone:802-878-9278
Mailing Address - Fax:
Practice Address - Street 1:67 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3235
Practice Address - Country:US
Practice Address - Phone:802-878-1003
Practice Address - Fax:802-878-9961
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT 0000304204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTJOVT-9125Medicaid
VTJOVT-9125Medicare ID - Type Unspecified
VTJOVT-9125Medicaid