Provider Demographics
NPI:1043375553
Name:JOHNSON, MATTHEW MARK (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3293
Mailing Address - Country:US
Mailing Address - Phone:775-359-0717
Mailing Address - Fax:775-359-1329
Practice Address - Street 1:1950 E GREG ST
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-6558
Practice Address - Country:US
Practice Address - Phone:775-359-0717
Practice Address - Fax:775-359-1329
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB0989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38161Medicare ID - Type Unspecified
NVU97312Medicare UPIN