Provider Demographics
NPI:1861427114
Name:JOHNSON, CALVIN M JR
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:M
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2427 SAINT CHARLES AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130-5825
Mailing Address - Country:US
Mailing Address - Phone:504-895-7642
Mailing Address - Fax:504-895-0728
Practice Address - Street 1:2427 SAINT CHARLES AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-5825
Practice Address - Country:US
Practice Address - Phone:504-895-7642
Practice Address - Fax:504-895-0728
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.010734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB63711Medicare UPIN
LA52238Medicare ID - Type Unspecified