Provider Demographics
NPI:1932183043
Name:JOHNSON, LARRY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
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 1:1015 GARDEN LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2779
Mailing Address - Country:US
Mailing Address - Phone:419-383-5500
Mailing Address - Fax:419-383-5575
Practice Address - Street 1:1015 GARDEN LAKE PKWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2779
Practice Address - Country:US
Practice Address - Phone:419-383-5500
Practice Address - Fax:419-383-5575
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0418793Medicaid
OHJO0581651Medicare ID - Type Unspecified
C03066Medicare UPIN