Provider Demographics
NPI:1063832079
Name:JOHNSON, OWEN (MD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 BARRY TRACE CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-2212
Mailing Address - Country:US
Mailing Address - Phone:614-389-3063
Mailing Address - Fax:614-389-3063
Practice Address - Street 1:3118 BARRY TRACE CT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2212
Practice Address - Country:US
Practice Address - Phone:614-389-3063
Practice Address - Fax:614-389-3063
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28260207R00000X
OH30-28260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine