Healthcare Provider Details

I. General information

NPI: 1033645577
Provider Name (Legal Business Name): MR. DONALD PETER JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NEW YORK AVE # 25A
SMITHTOWN NY
11787-3448
US

IV. Provider business mailing address

19 WILLETT AVE
SAYVILLE NY
11782-2319
US

V. Phone/Fax

Practice location:
  • Phone: 631-862-3000
  • Fax:
Mailing address:
  • Phone: 631-576-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340365
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: