Provider Demographics
NPI:1386836948
Name:JOHNSON, GUS JR
Entity Type:Individual
Prefix:MR
First Name:GUS
Middle Name:
Last Name:JOHNSON
Suffix:JR
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 1:750 OUIDA DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5446
Mailing Address - Country:US
Mailing Address - Phone:318-352-5961
Mailing Address - Fax:318-352-5965
Practice Address - Street 1:750 OUIDA DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5446
Practice Address - Country:US
Practice Address - Phone:318-352-5961
Practice Address - Fax:318-352-5965
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA109523747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1008869Medicaid