Provider Demographics
NPI:1497715262
Name:JOHNSON, JAY A (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 INGERSOLL AVENUE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5262
Mailing Address - Country:US
Mailing Address - Phone:515-279-6424
Mailing Address - Fax:515-279-3237
Practice Address - Street 1:2103 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-5262
Practice Address - Country:US
Practice Address - Phone:515-279-6424
Practice Address - Fax:515-279-3237
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1497715262Medicaid
IA0260901Medicaid
IA719260401Medicare PIN
IAI6653Medicare PIN
IAH74938Medicare UPIN
IA080194015Medicare PIN