MEDICARE: MR. DOUGLAS W JOHNSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	50-00-0344	OH

General Provider Information

NPI Number	:	1003816471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS W JOHNSON PA-C

Provider Business Mailing Address
First Line	:	3995 WILLOW RUN DR
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45430-1552
Country	:	US
Telephone Number	:	937-429-7132
Fax Number	:	937-224-5307

Provider Business Practice Location Address
First Line	:	1 ELIZABETH PL
Second Line	:	4TH FLOOR
City	:	DAYTON
State	:	OH
Zip	:	45408-1445
Country	:	US
Telephone Number	:	937-221-7001
Fax Number	:	937-224-5307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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