Provider Demographics
NPI:1629260914
Name:JOHNSON, DESMOND R
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:R
Last Name:JOHNSON
Suffix:
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 1:3400 COFFEE RD
Mailing Address - Street 2:APT 262
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:316-806-7508
Mailing Address - Fax:209-342-3237
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist