Provider Demographics
NPI:1467499418
Name:DAVID JOHNSON, M.D., P. A.
Entity Type:Organization
Organization Name:DAVID JOHNSON, M.D., P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-814-7150
Mailing Address - Street 1:775 POLE LINE RD W
Mailing Address - Street 2:SUITE 213
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5814
Mailing Address - Country:US
Mailing Address - Phone:208-814-8475
Mailing Address - Fax:208-734-4177
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 213
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8475
Practice Address - Fax:208-734-4177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2013-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM90862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003760400Medicaid
ID020051471OtherRR MEDICARE
ID1370638Medicare ID - Type UnspecifiedMEDICARE NUMBER
ID003760400Medicaid