Provider Demographics
NPI:1649381740
Name:JOHNSON, DOUGLAS R (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 SE 164TH AVE DEPT 358
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8004
Practice Address - Country:US
Practice Address - Phone:541-902-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO150688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR048884Medicaid
ORR0000ZGBDGOtherCURRY MEDICAL CENTER - MEDICARE PART B
OR93-0937095OtherCURRY HEALTH DISTRICT TAX ID
ORR0000ZGBDGOtherCURRY MEDICAL CENTER - MEDICARE PART B
ORR169383Medicare PIN