Provider Demographics
NPI:1619057973
Name:JOHNSON, REBECCA H (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 S L ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3720
Mailing Address - Country:US
Mailing Address - Phone:253-403-3481
Mailing Address - Fax:
Practice Address - Street 1:311 S L ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3720
Practice Address - Country:US
Practice Address - Phone:253-403-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL80902080P0207X
WAMD00048662208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164372801Medicaid
I02918Medicare UPIN
I02918Medicare UPIN