Basic Information
| Provider Information | |||||||||
| NPI: | 1942646203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | ALBUQUERQUE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721221 | ||||||||
| FaxNumber: | 5052729843 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | ALBUQUERQUE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721221 | ||||||||
| FaxNumber: | 5052729843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 02/16/2015 | ||||||||
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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 | 171M00000X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 45172871 | 05 | NM | MEDICAID |