Provider Demographics
NPI:1558516005
Name:CORY T JOHNSON MD PC
Entity Type:Organization
Organization Name:CORY T JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-274-2345
Mailing Address - Street 1:2301 MOUNTAIN VIEW BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1137
Mailing Address - Country:US
Mailing Address - Phone:541-850-0490
Mailing Address - Fax:541-850-0499
Practice Address - Street 1:3000 BRYANT WILLIAMS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1139
Practice Address - Country:US
Practice Address - Phone:541-274-2345
Practice Address - Fax:541-274-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24075207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty