Provider Demographics
NPI:1699016923
Name:JOHNSON, ADELRAS DUANE
Entity Type:Individual
Prefix:MR
First Name:ADELRAS
Middle Name:DUANE
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 1:1221 RESERVOIR RD APT 177
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-5724
Mailing Address - Country:US
Mailing Address - Phone:501-749-7676
Mailing Address - Fax:
Practice Address - Street 1:7107 W 12TH ST STE 201
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2451
Practice Address - Country:US
Practice Address - Phone:501-663-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator