Provider Demographics
NPI:1639775141
Name:DURBIN, JOHNNIE EDWIN
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:EDWIN
Last Name:DURBIN
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 1:230 BIRMINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1722
Mailing Address - Country:US
Mailing Address - Phone:760-230-1377
Mailing Address - Fax:
Practice Address - Street 1:230 BIRMINGHAM DR
Practice Address - Street 2:
Practice Address - City:CARDIFF BY THE SEA
Practice Address - State:CA
Practice Address - Zip Code:92007-1722
Practice Address - Country:US
Practice Address - Phone:760-230-1377
Practice Address - Fax:888-324-4764
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA298350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist