Provider Demographics
NPI:1659569267
Name:JOHNSON, STUART WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785
Mailing Address - Country:US
Mailing Address - Phone:605-347-4003
Mailing Address - Fax:605-347-6929
Practice Address - Street 1:824 1ST STREET
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785
Practice Address - Country:US
Practice Address - Phone:605-347-4003
Practice Address - Fax:605-347-6929
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1121111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604860Medicaid