Provider Demographics
NPI:1871141994
Name:JOHNSON, DEONDRE M
Entity type:Individual
Prefix:
First Name:DEONDRE
Middle Name:M
Last Name:JOHNSON
Suffix:
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 1:5009 C AND L AVE
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6355
Mailing Address - Country:US
Mailing Address - Phone:919-527-4148
Mailing Address - Fax:
Practice Address - Street 1:402 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1511
Practice Address - Country:US
Practice Address - Phone:919-527-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
U6174564304OtherCIGNA