Basic Information
| Provider Information | |||||||||
| NPI: | 1114928652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MADISON AVE | ||||||||
| Address2: | MID ATLANTIC SURGICAL ASSOC | ||||||||
| City: | MORRISTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079606136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739717300 | ||||||||
| FaxNumber: | 9739847019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1944 ROUTE 33 | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077534862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327764622 | ||||||||
| FaxNumber: | 7327763765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 62117 | NJ | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 5650909 | 05 | NJ | MEDICAID |