Provider Demographics
NPI:1083683247
Name:JOHANSEN, LAURENS FOSTER (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENS
Middle Name:FOSTER
Last Name:JOHANSEN
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 1:6352 PALOMINO WAY
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2242
Mailing Address - Country:US
Mailing Address - Phone:503-656-7371
Mailing Address - Fax:503-254-0656
Practice Address - Street 1:6352 PALOMINO WAY
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-2242
Practice Address - Country:US
Practice Address - Phone:503-656-7371
Practice Address - Fax:503-254-0656
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE59375Medicare UPIN
114450Medicare ID - Type Unspecified