Provider Demographics
NPI:1669448155
Name:JOHNSON, LARRY DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
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 1:2721 DEL PRADO BLVD S STE 250
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5710
Mailing Address - Country:US
Mailing Address - Phone:239-471-9070
Mailing Address - Fax:239-574-9454
Practice Address - Street 1:2721 DEL PRADO BLVD S STE 250
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5710
Practice Address - Country:US
Practice Address - Phone:239-471-9070
Practice Address - Fax:239-574-9454
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5495111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
350053600OtherRAILROAD MEDICARE
FL381717200Medicaid
350053600OtherRAILROAD MEDICARE
70987Medicare ID - Type Unspecified