Provider Demographics
NPI:1447389820
Name:JOHNSON, BLAINE A (DC)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4101
Mailing Address - Country:US
Mailing Address - Phone:443-903-2014
Mailing Address - Fax:443-903-2011
Practice Address - Street 1:722 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4101
Practice Address - Country:US
Practice Address - Phone:443-903-2014
Practice Address - Fax:443-903-2011
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD705RMedicare ID - Type UnspecifiedPROVIDER NUMBER
MDU86792Medicare UPIN