Provider Demographics
NPI:1467420422
Name:JOHNSEN, DAVID ROBERT (NAVY IDC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROBERT
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 BOB OFARRELL LN
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-4512
Mailing Address - Country:US
Mailing Address - Phone:847-263-8867
Mailing Address - Fax:
Practice Address - Street 1:3001A SIXTH STREET
Practice Address - Street 2:NAVAL HOSPITAL FISHER CLINIC
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-2469
Practice Address - Fax:847-688-2512
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman