Provider Demographics
NPI:1053494294
Name:JOHNSON, DEBORAH M (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4276
Mailing Address - Country:US
Mailing Address - Phone:503-585-9695
Mailing Address - Fax:503-581-3960
Practice Address - Street 1:1395 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4276
Practice Address - Country:US
Practice Address - Phone:503-585-9695
Practice Address - Fax:503-581-3960
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16845207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022538Medicaid
OR022538Medicaid
ORR177630Medicare PIN