Provider Demographics
NPI:1558342212
Name:JOHNSON, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
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 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-538-2698
Mailing Address - Fax:503-554-9328
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:SUITE 340
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7485
Practice Address - Country:US
Practice Address - Phone:503-538-2698
Practice Address - Fax:503-554-9328
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 15167207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR157975OtherMEDICARE PTAN
OR176842Medicaid
OR176842Medicaid