Provider Demographics
NPI:1750392676
Name:JOHNSON, DUANE P (DO)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12404 LIMA CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-0202
Mailing Address - Country:US
Mailing Address - Phone:260-478-4201
Mailing Address - Fax:260-458-3248
Practice Address - Street 1:12404 LIMA CROSSING DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-0202
Practice Address - Country:US
Practice Address - Phone:260-478-4201
Practice Address - Fax:260-458-3248
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009629207Q00000X
FLOS16751207Q00000X
IN02003311A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111360400Medicaid
IN200942660Medicaid
OH2968963Medicaid