Provider Demographics
NPI:1770748063
Name:JOHNSON, DIRK C (MD)
Entity type:Individual
Prefix:DR
First Name:DIRK
Middle Name:C
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 1:330 CEDAR ST # BB 310
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3218
Mailing Address - Country:US
Mailing Address - Phone:203-785-2572
Mailing Address - Fax:203-785-3950
Practice Address - Street 1:330 CEDAR ST
Practice Address - Street 2:BB 310
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-2572
Practice Address - Fax:203-785-3950
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044811208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery