Provider Demographics
NPI:1437129186
Name:JOHNSON, GARY K (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:K
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 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-336-2178
Mailing Address - Fax:360-336-1674
Practice Address - Street 1:118 S 12TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4036
Practice Address - Country:US
Practice Address - Phone:360-336-2178
Practice Address - Fax:360-336-1995
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011699207YS0123X, 207YX0602X, 207YX0905X, 208200000X, 2086S0122X, 207Y00000X, 2086S0122X, 2086X0206X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1010297Medicaid
WAMD00011699OtherWA STATE MEDICAL LICENSE
WAMD00011699OtherWA STATE MEDICAL LICENSE
WAD33846Medicare UPIN
WA1429307Medicaid