Basic Information
| Provider Information | |||||||||
| NPI: | 1932183043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 GARDEN LAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835500 | ||||||||
| FaxNumber: | 4193835575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 GARDEN LAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835500 | ||||||||
| FaxNumber: | 4193835575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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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 | 207Q00000X | 35043619 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0418793 | 05 | OH | MEDICAID |