Provider Demographics
NPI:1669435897
Name:JOHNSON, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062183207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH727072OtherBUCKEYE COMMUNITY IND #
OH0905720Medicaid
OH000000364938OtherBC/BS INDIVIDUAL NUMBER
OHP00212614OtherRAILROAD MEDICARE IND #
OHP00212614OtherRAILROAD MEDICARE IND #
JO0832493Medicare PIN