Provider Demographics
NPI:1871881052
Name:JOHNSON, CHAD J (DO)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 1301
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3467
Mailing Address - Country:US
Mailing Address - Phone:208-735-8585
Mailing Address - Fax:208-933-2001
Practice Address - Street 1:1411 FALLS AVE E STE 1301
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3467
Practice Address - Country:US
Practice Address - Phone:208-735-8585
Practice Address - Fax:208-933-2001
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8974078-1204207Q00000X
390200000X
IDO-0694207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program