Provider Demographics
NPI:1366491045
Name:JOHANSEN, KAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:KAJ
Middle Name:
Last Name:JOHANSEN
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:PO BOX 22152
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-0152
Mailing Address - Country:US
Mailing Address - Phone:206-420-3119
Mailing Address - Fax:206-453-5912
Practice Address - Street 1:600 BROADWAY STE 112
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5381
Practice Address - Country:US
Practice Address - Phone:206-420-3119
Practice Address - Fax:206-453-5912
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000164862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8400103Medicaid
WA8400103Medicaid
WA8875089Medicare PIN