Provider Demographics
NPI:1598765661
Name:JOHNSON, DARRYL L (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:L
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 1:400 EAST VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270
Mailing Address - Country:US
Mailing Address - Phone:318-251-0620
Mailing Address - Fax:318-251-0621
Practice Address - Street 1:400 EAST VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-251-0620
Practice Address - Fax:318-251-0621
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9808207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1096342Medicaid
LA5K007Medicare ID - Type Unspecified
LA1096342Medicaid