Provider Demographics
NPI:1568447969
Name:JOHNSON, RICHARD E (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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 1:90 BEAVER DR
Mailing Address - Street 2:STE 122-D
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2440
Mailing Address - Country:US
Mailing Address - Phone:814-375-4466
Mailing Address - Fax:
Practice Address - Street 1:90 BEAVER DR
Practice Address - Street 2:STE 122-D
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2440
Practice Address - Country:US
Practice Address - Phone:814-375-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006605L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1174971Medicaid
PA1174971Medicaid
JO525803Medicare ID - Type Unspecified