Basic Information
| Provider Information | |||||||||
| NPI: | 1396803763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ELLSWORTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6852 | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999011852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072256396 | ||||||||
| FaxNumber: | 9072475951 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 TONGASS AVE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072254463 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 1160 | AK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | MD1213 | 05 | AK | MEDICAID | R004 | 01 | AK | TRICARE | OTHER |