Provider Demographics
NPI:1598867038
Name:JOHNSON, OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:
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 1:3824 CEDAR SPRINGS RD
Mailing Address - Street 2:#801-14364
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4136
Mailing Address - Country:US
Mailing Address - Phone:915-838-5903
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239663208200000X, 2082S0099X, 208600000X, 208D00000X, 208D00000X
WAMD61266495208200000X
MDD791272082S0099X, 208600000X, 2086S0122X
TXR17852086S0122X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery