Provider Demographics
NPI:1861600314
Name:JOHNSON, JOHN EDWARD JR (DC,LAC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:631-691-3557
Mailing Address - Fax:
Practice Address - Street 1:75 UNION AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-691-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor