Provider Demographics
NPI:1528035565
Name:JOHNSON, ALLEN L (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:L
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:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1990 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9315
Practice Address - Country:US
Practice Address - Phone:360-856-4222
Practice Address - Fax:360-854-2792
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031995208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8181331Medicaid
WA8205072Medicaid
WAF90973Medicare UPIN
8852583Medicare PIN
WA8181331Medicaid