Individual
MR. RUSSELL JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
601 OLD WAGNER RD, SUITE 101, PETERSBURG, VA 23805-9313
(804) 524-2260
(804) 524-0096
Mailing address
601 OLD WAGNER RD, SUITE 101, PETERSBURG, VA 23805-9313
(804) 524-2260
(804) 524-0096
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
0101045410
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
194501
ANTHEM
VA
Enumeration date
05/24/2006
Last updated
07/07/2016
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