Healthcare Provider Details

I. General information

NPI: 1609223387
Provider Name (Legal Business Name): MR. GARY JOHNSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 HAWAII AVE NE #111
WASHINGTON DC
20011
US

IV. Provider business mailing address

50 HAWAII AVE NE #111
WASHINGTON DC
20011-4980
US

V. Phone/Fax

Practice location:
  • Phone: 202-813-9452
  • Fax: 702-549-2450
Mailing address:
  • Phone: 202-813-9452
  • Fax: 702-549-2450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: