Provider Demographics
NPI:1578936647
Name:JOHNSON, ANTONIO DEMETRIUS JR (AT,C)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:DEMETRIUS
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 A ST
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-2009
Mailing Address - Country:US
Mailing Address - Phone:716-990-3308
Mailing Address - Fax:
Practice Address - Street 1:48 A ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14303-2009
Practice Address - Country:US
Practice Address - Phone:716-990-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083043-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer