Provider Demographics
NPI:1245106467
Name:JOHNSON, VLADIK
Entity type:Individual
Prefix:
First Name:VLADIK
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 1:428 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:SD
Mailing Address - Zip Code:57523-2020
Mailing Address - Country:US
Mailing Address - Phone:605-208-1832
Mailing Address - Fax:
Practice Address - Street 1:428 E 13TH ST
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:SD
Practice Address - Zip Code:57523-2020
Practice Address - Country:US
Practice Address - Phone:605-208-1832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6115225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty