Provider Demographics
NPI:1942646203
Name:JOHNSON, DAVID A
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:2600 MARBLE AVE NE
Mailing Address - Street 2:ALBUQUERQUE
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2058
Mailing Address - Country:US
Mailing Address - Phone:505-272-1221
Mailing Address - Fax:505-272-9843
Practice Address - Street 1:2600 MARBLE AVE NE
Practice Address - Street 2:ALBUQUERQUE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2058
Practice Address - Country:US
Practice Address - Phone:505-272-1221
Practice Address - Fax:505-272-9843
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45172871Medicaid