Provider Demographics
NPI:1275691131
Name:JOHNSON, GREGORY JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAY
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 1:54-289 HAUULA HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:HAUULA
Mailing Address - State:HI
Mailing Address - Zip Code:96717-9635
Mailing Address - Country:US
Mailing Address - Phone:808-927-7475
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
08WCBBSCQMedicare ID - Type Unspecified
C91119Medicare UPIN