Provider Demographics
NPI:1285622183
Name:JOHNSON, DEREK K (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903A FAIR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2938
Mailing Address - Country:US
Mailing Address - Phone:703-648-0030
Mailing Address - Fax:703-648-9028
Practice Address - Street 1:3903A FAIR RIDGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2938
Practice Address - Country:US
Practice Address - Phone:703-648-0030
Practice Address - Fax:703-648-9028
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 065160L2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018751530003Medicaid
PA0018751530003Medicaid
059180Medicare ID - Type Unspecified