Provider Demographics
NPI:1841379187
Name:JOHNSON, DWAYNE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:148 W HIVELY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-2191
Mailing Address - Country:US
Mailing Address - Phone:574-350-2500
Mailing Address - Fax:574-350-2598
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4666
Practice Address - Country:US
Practice Address - Phone:574-584-7373
Practice Address - Fax:574-293-3744
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073977A208000000X
KY28666208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
611336483OtherCOMMONWEALTH HEALTH ALLIA
611336483OtherMAIL HANDLERS BENEFIT PLA
611336483OtherPPONEXT
KY642886669Medicaid
IN200287610BMedicaid
611336483OtherUNITED HEALTHCARE
2435769000OtherPASSPORT ADVANTAGE
611336483OtherHUMANA HEALTH PLAN, INC.
1087687OtherPASSPORT HEALTH PLAN
611336483OtherPREFERRED HEALTH PLAN
000000052119OtherANTHEM
2133380OtherAETNA
611336483Other4MOST HEALTH NETWORK
87043OtherFIRST HEALTH NETWORK
611336483OtherCOMMONWEALTH HEALTH ALLIA