Provider Demographics
NPI:1508465501
Name:JOHNSON, DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JOHNSON
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 1:5398 PERSHING AVE APT 3W
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1788
Mailing Address - Country:US
Mailing Address - Phone:931-302-1595
Mailing Address - Fax:
Practice Address - Street 1:1905 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4025
Practice Address - Country:US
Practice Address - Phone:575-885-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5790208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation