Provider Demographics
NPI:1629481379
Name:JOHNSON, BENNETT M (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:21616 76TH AVE W STE 201A
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7512
Practice Address - Country:US
Practice Address - Phone:425-673-3400
Practice Address - Fax:425-673-3401
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2021-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60864242208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery