Healthcare Provider Details

I. General information

NPI: 1316005960
Provider Name (Legal Business Name): JOHN RUSSELL JOHANSSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 LINCOLN ST
ESSEX JUNCTION VT
05452-3235
US

IV. Provider business mailing address

67 LINCOLN ST
ESSEX JUNCTION VT
05452-3235
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-1003
  • Fax: 802-878-9961
Mailing address:
  • Phone: 802-878-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberVT 0000304
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: