Provider Demographics
NPI:1124362066
Name:GORDON R JOHNSON D O P C
Entity Type:Organization
Organization Name:GORDON R JOHNSON D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:563-391-3309
Mailing Address - Street 1:3906 LILLIE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-4434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3906 LILLIE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-4434
Practice Address - Country:US
Practice Address - Phone:563-391-3309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1926207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty