Provider Demographics
NPI:1164794202
Name:JOHNSON, FREDERICK FARMAN III (LMT)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:FARMAN
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 NE IRVING AVE.
Mailing Address - Street 2:102
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:334 NE IRVING AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-419-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18101171W00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractor