Provider Demographics
NPI:1083601835
Name:JOHNSON, THOMAS HARRY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HARRY
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 1:3620 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1106
Mailing Address - Country:US
Mailing Address - Phone:503-280-2931
Mailing Address - Fax:503-280-2938
Practice Address - Street 1:3620 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1106
Practice Address - Country:US
Practice Address - Phone:503-280-2931
Practice Address - Fax:503-280-2938
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD135902085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR109399Medicare PIN
ORR00WCGNMCMedicare PIN
WAG8865241Medicare PIN