Provider Demographics
NPI:1396711966
Name:JOHNSON, DAVID MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
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 1:111 COLCHESTER AVE
Mailing Address - Street 2:DEPT RADIOLOGY
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-3592
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224406174400000X
VA01012634162085N0700X
VT042-00117492085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No174400000XOther Service ProvidersSpecialist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02421850Medicaid
NYG29345Medicare UPIN
NY890371Medicare ID - Type UnspecifiedEMPIRE MEDICARE