Healthcare Provider Details

I. General information

NPI: 1972714640
Provider Name (Legal Business Name): DAVID CARL JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 GRANITE DR
RENO NV
89509-3999
US

IV. Provider business mailing address

1675 GRANITE DR
RENO NV
89509-3999
US

V. Phone/Fax

Practice location:
  • Phone: 775-825-7567
  • Fax: 775-825-7567
Mailing address:
  • Phone: 775-825-7567
  • Fax: 775-825-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2311
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: