Provider Demographics
NPI:1033268404
Name:JOHNSON, GARY A (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
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 1:417 E POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7609
Mailing Address - Country:US
Mailing Address - Phone:503-665-2517
Mailing Address - Fax:503-667-3239
Practice Address - Street 1:417 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7609
Practice Address - Country:US
Practice Address - Phone:503-665-2517
Practice Address - Fax:503-667-3239
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22894111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician