Provider Demographics
NPI:1780647958
Name:JOHNSON, VAN WARREN (MD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:WARREN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W SAINT CLAIR ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2197
Mailing Address - Country:US
Mailing Address - Phone:814-726-1921
Mailing Address - Fax:814-726-7881
Practice Address - Street 1:103 W SAINT CLAIR ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2197
Practice Address - Country:US
Practice Address - Phone:814-726-1921
Practice Address - Fax:814-726-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD013857E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006530430001Medicaid
PA108296OtherMEDICARE ID
PAC30224Medicare UPIN