Provider Demographics
NPI:1457685745
Name:JOHANSON, DAVID DONALD (DPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:DONALD
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 COUNTRY CLUB RD STE 800
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-2400
Mailing Address - Country:US
Mailing Address - Phone:910-939-5759
Mailing Address - Fax:
Practice Address - Street 1:2145 COUNTRY CLUB RD STE 800
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-2400
Practice Address - Country:US
Practice Address - Phone:910-939-5759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031807-1225100000X
NCP18398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist