Healthcare Provider Details

I. General information

NPI: 1447205554
Provider Name (Legal Business Name): MR. RUSSELL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 OLD WAGNER RD SUITE 101
PETERSBURG VA
23805-9313
US

IV. Provider business mailing address

601 OLD WAGNER RD SUITE 101
PETERSBURG VA
23805-9313
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-2260
  • Fax: 804-524-0096
Mailing address:
  • Phone: 804-524-2260
  • Fax: 804-524-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101045410
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: