MEDICARE: JOHN DEREK JOHNSON MD

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	207Q00000X	Family Medicine Physician	206647	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619234945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN DEREK JOHNSON MD

Provider Business Mailing Address
First Line	:	PO BOX 2780
Second Line	:	LASALLE FAMILY MEDICINE CLINIC
City	:	JENA
State	:	LA
Zip	:	71342-2780
Country	:	US
Telephone Number	:	318-992-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 NINTH ST
Second Line	:	LASALLE FAMILY MEDICINE CLINIC
City	:	JENA
State	:	LA
Zip	:	71342-3900
Country	:	US
Telephone Number	:	318-992-9200
Fax Number	:

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

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	07/07/2015

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