Provider Demographics
NPI:1255077475
Name:DARAMOLA, JOHNSON
Entity type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:DARAMOLA
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 1:473 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1207
Mailing Address - Country:US
Mailing Address - Phone:862-267-8249
Mailing Address - Fax:
Practice Address - Street 1:473 S 18TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-1207
Practice Address - Country:US
Practice Address - Phone:862-267-8249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness