Provider Demographics
NPI:1619234945
Name:JOHNSON, JOHN DEREK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DEREK
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:PO BOX 2780
Mailing Address - Street 2:LASALLE FAMILY MEDICINE CLINIC
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-2780
Mailing Address - Country:US
Mailing Address - Phone:318-992-9200
Mailing Address - Fax:
Practice Address - Street 1:180 NINTH ST
Practice Address - Street 2:LASALLE FAMILY MEDICINE CLINIC
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-3900
Practice Address - Country:US
Practice Address - Phone:318-992-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2188658Medicaid