Healthcare Provider Details

I. General information

NPI: 1902542004
Provider Name (Legal Business Name): DOUGLAS JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 7TH ST
HEBER SPRINGS AR
72543-3718
US

IV. Provider business mailing address

201 S 7TH ST
HEBER SPRINGS AR
72543-3718
US

V. Phone/Fax

Practice location:
  • Phone: 501-362-8118
  • Fax: 501-362-8119
Mailing address:
  • Phone: 501-362-8118
  • Fax: 501-362-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4559
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: