Provider Demographics
NPI:1780624007
Name:JOHNSON, DAVID WILMER (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WILMER
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 1:723 MEMORIAL ST
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1524
Mailing Address - Country:US
Mailing Address - Phone:509-786-2222
Mailing Address - Fax:509-786-6612
Practice Address - Street 1:723 MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1524
Practice Address - Country:US
Practice Address - Phone:509-786-2222
Practice Address - Fax:509-786-6612
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306897681OtherPMH NPI #
WA8628703Medicaid
WA501312Medicare Oscar/Certification
WA8628703Medicaid