Healthcare Provider Details

I. General information

NPI: 1275938680
Provider Name (Legal Business Name): GABRIEL DAVID JOHNSON D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N WASHINGTON ST
VIBORG SD
57070-2002
US

IV. Provider business mailing address

PO BOX 368
VIBORG SD
57070-0368
US

V. Phone/Fax

Practice location:
  • Phone: 605-326-5201
  • Fax: 605-326-5196
Mailing address:
  • Phone: 605-326-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11074
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: