Provider Demographics
NPI:1942051107
Name:JOHNSON, JONATHAN IDICULA (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:IDICULA
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 W 1ST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4220
Mailing Address - Country:US
Mailing Address - Phone:336-716-4479
Mailing Address - Fax:
Practice Address - Street 1:1920 W 1ST ST FL 3
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4220
Practice Address - Country:US
Practice Address - Phone:336-716-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program