Provider Demographics
NPI:1629302898
Name:JOHNSON, CLIFFORD JAMES (HIS)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15816 N PENN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7307
Mailing Address - Country:US
Mailing Address - Phone:405-755-6557
Mailing Address - Fax:405-755-6577
Practice Address - Street 1:15816 N. PENN.
Practice Address - Street 2:STE 2
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-755-6557
Practice Address - Fax:405-755-6577
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK842237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist