Provider Demographics
NPI:1417029737
Name:JOHNSON, DAVID ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
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:PO BOX 2123
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70054
Mailing Address - Country:US
Mailing Address - Phone:504-305-4790
Mailing Address - Fax:504-305-4790
Practice Address - Street 1:1057 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070
Practice Address - Country:US
Practice Address - Phone:985-785-6242
Practice Address - Fax:985-785-3686
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12764R2085R0202X
LAMD12764R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1543802Medicaid
LA5A874Medicare PIN
LAG76380Medicare UPIN