Provider Demographics
NPI:1588859599
Name:JOHNSON, DERRICK J (PT)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N BROADWAY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-6039
Mailing Address - Country:US
Mailing Address - Phone:405-609-3675
Mailing Address - Fax:800-506-3795
Practice Address - Street 1:717 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5207
Practice Address - Country:US
Practice Address - Phone:580-225-0848
Practice Address - Fax:580-225-0873
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist