=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609900604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD E JOHNSON, DO, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 10/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 BEAVER DR STE 122-D
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-375-4466
-----------------------------------------------------
Fax | 814-375-4468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 BEAVER DR STE 122-D
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-375-4466
-----------------------------------------------------
Fax | 814-375-4468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD E JOHNSON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 814-375-4466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OS006605L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------