Provider Demographics
NPI:1497701643
Name:JOHNSON, ERIC G (RPT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-3303
Mailing Address - Country:US
Mailing Address - Phone:580-338-4676
Mailing Address - Fax:580-338-4686
Practice Address - Street 1:1311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3303
Practice Address - Country:US
Practice Address - Phone:580-338-4676
Practice Address - Fax:580-338-4686
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist