Provider Demographics
NPI:1952803314
Name:JOHNSON, DAVID M (CADC I)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1538
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-0115
Mailing Address - Country:US
Mailing Address - Phone:541-574-9570
Mailing Address - Fax:541-574-8857
Practice Address - Street 1:1345 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-3327
Practice Address - Country:US
Practice Address - Phone:541-574-9570
Practice Address - Fax:541-574-8857
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-P-06174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist