Healthcare Provider Details

I. General information

NPI: 1285622183
Provider Name (Legal Business Name): DEREK K JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903A FAIR RIDGE DR
FAIRFAX VA
22033-2938
US

IV. Provider business mailing address

3903A FAIR RIDGE DR
FAIRFAX VA
22033-2938
US

V. Phone/Fax

Practice location:
  • Phone: 703-648-0030
  • Fax: 703-648-9028
Mailing address:
  • Phone: 703-648-0030
  • Fax: 703-648-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101230706
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: