Provider Demographics
NPI:1508837741
Name:JOHNSON, DAVID H (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5814 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18080 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:VA
Practice Address - Zip Code:24066-5482
Practice Address - Country:US
Practice Address - Phone:540-254-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-231013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010112907Medicaid
VA1508837741Medicaid
VA010194962Medicaid
080194023Medicare PIN
006282C95Medicare PIN
015094C47Medicare PIN
000182C51Medicare PIN
008332C41Medicare PIN
VA010194962Medicaid