Provider Demographics
NPI:1609223387
Name:JOHNSON, GARY JR
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 HAWAII AVE NE
Mailing Address - Street 2:#111
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4980
Mailing Address - Country:US
Mailing Address - Phone:202-813-9452
Mailing Address - Fax:702-549-2450
Practice Address - Street 1:50 HAWAII AVE NE
Practice Address - Street 2:#111
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011
Practice Address - Country:US
Practice Address - Phone:202-813-9452
Practice Address - Fax:702-549-2450
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty