Healthcare Provider Details

I. General information

NPI: 1104241595
Provider Name (Legal Business Name): CODY REID JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2014
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6301
  • Fax: 570-271-5976
Mailing address:
  • Phone: 570-271-6301
  • Fax: 570-271-5976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD486964
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: