Provider Demographics
NPI:1104041813
Name:JOHNSON, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
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 1:748 SE FAIRWINDS LOOP
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-8087
Mailing Address - Country:US
Mailing Address - Phone:360-695-8476
Mailing Address - Fax:360-567-3033
Practice Address - Street 1:748 SE FAIRWINDS LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-8087
Practice Address - Country:US
Practice Address - Phone:360-695-8476
Practice Address - Fax:360-567-3033
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000285742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA363606565OtherTIN
WA363606565OtherTIN
WAD93840Medicare UPIN