Provider Demographics
NPI:1255680831
Name:JOHANSEN, MARK RONALD (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RONALD
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14661 SE 172ND AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7771
Mailing Address - Country:US
Mailing Address - Phone:503-998-5314
Mailing Address - Fax:
Practice Address - Street 1:12762 SE STARK ST
Practice Address - Street 2:PLAZA 125 BLDG. D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-255-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor