Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0201X | Pediatric Allergist | MD 065160L | PA |
NPI | 1285622183 |
---|---|
Provider Name | Derek K Johnson |
First Address | Fairfax, VA 22033-2938 |
Second Address | Fairfax, VA 22033-2938 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2005 |
Last Update Date | 27/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0018751530003 | (05) | PA |
H64721 | (02) |