Provider Demographics
NPI:1629343926
Name:RODNEY J JOHNSON, MD, PS, INC
Entity Type:Organization
Organization Name:RODNEY J JOHNSON, MD, PS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:425-455-5440
Mailing Address - Street 1:1600 116TH AVE NE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3014
Mailing Address - Country:US
Mailing Address - Phone:425-455-5440
Mailing Address - Fax:425-455-1431
Practice Address - Street 1:1600 116TH AVE NE
Practice Address - Street 2:SUITE 302
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3014
Practice Address - Country:US
Practice Address - Phone:425-455-5440
Practice Address - Fax:425-455-1431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00020967261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1096478Medicaid
WAA06212Medicare UPIN