Provider Demographics
NPI:1417088535
Name:JOHNSON, STEPHEN D (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 E HARBOR ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9717
Mailing Address - Country:US
Mailing Address - Phone:503-861-1661
Mailing Address - Fax:503-861-1662
Practice Address - Street 1:679 E HARBOR ST
Practice Address - Street 2:SUITE 140
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9717
Practice Address - Country:US
Practice Address - Phone:503-861-1661
Practice Address - Fax:503-861-1662
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 1793111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00WCKCJBMedicare ID - Type UnspecifiedPROVIDER NUMBER