Provider Demographics
NPI:1710185376
Name:JOHNSON, PHILLIP W (CPO)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7019
Mailing Address - Country:US
Mailing Address - Phone:540-951-2566
Mailing Address - Fax:540-951-7818
Practice Address - Street 1:3635 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7019
Practice Address - Country:US
Practice Address - Phone:540-951-2566
Practice Address - Fax:540-951-7818
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCPO 02395222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5401900001OtherDMERC MEDICARE
VA175522OtherANTHEM BCBS