Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 5815 | NE |
NPI | 1013179001 |
---|---|
Provider Name | Dr. Justin Dale Johnson |
First Address | Lexington, KY 40504-3751 |
Second Address | Lexington, KY 40504-3751 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2008 |
Last Update Date | 06/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5815 | TEP (01) | NE |