Provider Demographics
NPI:1487644563
Name:JOHNSON, NOEL THEODORE (DO)
Entity Type:Individual
Prefix:DR
First Name:NOEL
Middle Name:THEODORE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
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 5730
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98046-5730
Mailing Address - Country:US
Mailing Address - Phone:425-742-5512
Mailing Address - Fax:
Practice Address - Street 1:9801 FRONTIER AVE SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-5200
Practice Address - Country:US
Practice Address - Phone:425-831-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001006207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1017672Medicaid
WAD33832Medicare UPIN
WA1017672Medicaid