Provider Demographics
NPI:1306820402
Name:JOHANSEN, LYNDON G (DPM)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:G
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12658 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:503-256-4018
Mailing Address - Fax:503-256-6298
Practice Address - Street 1:12658 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-256-4018
Practice Address - Fax:503-256-6298
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00230213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR045653Medicaid
OR4665150001Medicare NSC
OR045653Medicaid
U31741Medicare UPIN