Provider Demographics
NPI:1417454547
Name:JOHNSON, EARL DEAN
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
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 1:7206 STONE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7359
Mailing Address - Country:US
Mailing Address - Phone:540-841-3346
Mailing Address - Fax:
Practice Address - Street 1:7206 STONE CROSSING DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7359
Practice Address - Country:US
Practice Address - Phone:540-841-3346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705113047171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2705113047Medicaid