Provider Demographics
NPI:1639145030
Name:JOHANSEN, GEORGE WALLACE (MM)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALLACE
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:MM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 HILYARD ST
Practice Address - Street 2:SUITE S-200
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8122
Practice Address - Country:US
Practice Address - Phone:541-685-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD06490207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR242016Medicaid
ORR04WFBFRAMedicare PIN
ORRR PTAN 040008452Medicare PIN
OR242016Medicaid