Basic Information
| Provider Information | |||||||||
| NPI: | 1669435897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 2213 CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436082603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192513232 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35062183 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 727072 | 01 | OH | BUCKEYE COMMUNITY IND # | OTHER | 0905720 | 05 | OH | MEDICAID | 000000364938 | 01 | OH | BC/BS INDIVIDUAL NUMBER | OTHER | P00212614 | 01 | OH | RAILROAD MEDICARE IND # | OTHER |