Healthcare Provider Details
I. General information
NPI: 1841379187
Provider Name (Legal Business Name): DWAYNE EDWARD JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 11/06/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:
III. Provider practice location address
236 SIMPSON AVE
ELKHART IN
46516-4666
US
IV. Provider business mailing address
148 W HIVELY AVE SUITE 1
ELKHART IN
46517-2191
US
V. Phone/Fax
- Phone: 574-584-7373
- Fax: 574-293-3744
- Phone: 574-350-2500
- Fax: 574-350-2598
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 01073977A |
| License Number State | IN |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 28666 |
| License Number State | KY |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | COMMONWEALTH HEALTH ALLIA |
| # 2 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | MAIL HANDLERS BENEFIT PLA |
| # 3 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PPONEXT |
| # 4 | |
| Identifier | 642886669 |
| Identifier Type | MEDICAID |
| Identifier State | KY |
| Identifier Issuer | |
| # 5 | |
| Identifier | 200287610B |
| Identifier Type | MEDICAID |
| Identifier State | IN |
| Identifier Issuer | |
| # 6 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | UNITED HEALTHCARE |
| # 7 | |
| Identifier | 2435769000 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PASSPORT ADVANTAGE |
| # 8 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | HUMANA HEALTH PLAN, INC. |
| # 9 | |
| Identifier | 1087687 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PASSPORT HEALTH PLAN |
| # 10 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PREFERRED HEALTH PLAN |
| # 11 | |
| Identifier | 000000052119 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | ANTHEM |
| # 12 | |
| Identifier | 2133380 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | AETNA |
| # 13 | |
| Identifier | 611336483 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | 4MOST HEALTH NETWORK |
| # 14 | |
| Identifier | 87043 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | FIRST HEALTH NETWORK |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
