Provider Demographics
NPI:1659363190
Name:JOHNSON, JOSHUA LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LAURENCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7521
Practice Address - Country:US
Practice Address - Phone:503-537-5900
Practice Address - Fax:503-537-5959
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4763192084N0400X
GA879932084N0400X
FLME148042084N0400X
MT918902084N0400X
NH215432084N0400X
ORMD235162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227430Medicaid
WA8385973Medicaid
WA8554818Medicare PIN
ORH93274Medicare UPIN
OR227430Medicaid