Provider Demographics
NPI:1639147697
Name:JOHNSON, WAYNE CARLETON (IDC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:CARLETON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3848B WESTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9407
Mailing Address - Country:US
Mailing Address - Phone:760-368-2149
Mailing Address - Fax:760-830-2601
Practice Address - Street 1:NAVAL HOSPITAL
Practice Address - Street 2:BOX 788250
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8250
Practice Address - Country:US
Practice Address - Phone:760-830-2677
Practice Address - Fax:760-830-2601
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman