Provider Demographics
NPI:1750517967
Name:JOHNSON, DOUGLAS (PT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 PAWTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6057
Mailing Address - Country:US
Mailing Address - Phone:401-722-2400
Mailing Address - Fax:401-728-3920
Practice Address - Street 1:588 PAWTUCKET AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6057
Practice Address - Country:US
Practice Address - Phone:401-722-2400
Practice Address - Fax:401-728-3920
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT00271-G225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT02233OtherRI STATE LICENSE NUMBER
RI1780672709OtherGROUP NPI NUMBER