Provider Demographics
NPI:1336328624
Name:JOHNSON, JUSTIN THEO (DPM)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:THEO
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:1661 HWY 99 N STE 201
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-8900
Mailing Address - Country:US
Mailing Address - Phone:541-482-4924
Mailing Address - Fax:541-488-1732
Practice Address - Street 1:1661 HIGHWAY 99 N
Practice Address - Street 2:STE 201
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-8900
Practice Address - Country:US
Practice Address - Phone:541-482-4924
Practice Address - Fax:541-488-1732
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDPOO440213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1336328624OtherNPI
ORDP00440OtherSTATE MEDICAL LICENSE NUMBER