Provider Demographics
NPI:1275514911
Name:JOHNSON, LARRY HUGH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:HUGH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:H
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7643 OAK PARK PL NW
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9175
Mailing Address - Country:US
Mailing Address - Phone:360-692-2399
Mailing Address - Fax:
Practice Address - Street 1:7643 OAK PARK PL NW
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-9175
Practice Address - Country:US
Practice Address - Phone:360-692-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037208207Q00000X
NC2001-01071207Q00000X
OH35-04-0609-J207Q00000X
NM2003-0111207Q00000X
KY36892207Q00000X
ARE-4454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC01704Medicare UPIN