Basic Information
| Provider Information | |||||||||
| NPI: | 1093728677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A.L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072829080 | ||||||||
| FaxNumber: | 2072829180 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WELLSPRING RD | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072831126 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 017983 | ME | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 433319099 | 05 | ME | MEDICAID | 7318687 | 01 | ME | AETNA | OTHER | AA134371 | 01 | ME | HARVARD PILGRIM HEALTHCARE | OTHER | 1093728677 | 01 | ME | ANTHEM | OTHER | 1093728677 | 05 | ME | MEDICAID |