Provider Demographics
NPI:1801842968
Name:DAVID P JOHNSON
Entity Type:Organization
Organization Name:DAVID P JOHNSON
Other - Org Name:JOHNSON PORTABLE XRAY SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RTR
Authorized Official - Phone:815-544-7120
Mailing Address - Street 1:8198 COMMERCE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-5710
Mailing Address - Country:US
Mailing Address - Phone:815-544-7120
Mailing Address - Fax:815-885-4271
Practice Address - Street 1:8198 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-5710
Practice Address - Country:US
Practice Address - Phone:815-544-7120
Practice Address - Fax:815-885-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL500498218335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
149840Medicare UPIN