Provider Demographics
NPI:1790990679
Name:JOHNSON, RUSSELL E (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:E
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 1:1519 GRUNDY AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2106
Mailing Address - Country:US
Mailing Address - Phone:631-588-9806
Mailing Address - Fax:
Practice Address - Street 1:1519 GRUNDY AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2106
Practice Address - Country:US
Practice Address - Phone:631-588-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003142111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor