Provider Demographics
NPI:1780196618
Name:JOHNSON, MATT DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:DAVID
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 1:4925 EVERHART RD STE 109
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-3954
Mailing Address - Country:US
Mailing Address - Phone:469-734-5822
Mailing Address - Fax:
Practice Address - Street 1:4925 EVERHART RD STE 109
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-3954
Practice Address - Country:US
Practice Address - Phone:469-734-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty