Provider Demographics
NPI:1841804044
Name:JOHNSON, DAVID
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 DAVIS GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5631
Mailing Address - Country:US
Mailing Address - Phone:662-932-1439
Mailing Address - Fax:
Practice Address - Street 1:4436 DAVIS GROVE BLVD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-5631
Practice Address - Country:US
Practice Address - Phone:662-932-1439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide