Provider Demographics
NPI:1659664126
Name:JOHNSON, DONALD HARVEY (MD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:HARVEY
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 1:691 MURPHY ROAD
Mailing Address - Street 2:SUITE 122
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-772-5437
Mailing Address - Fax:541-857-2852
Practice Address - Street 1:691 MURPHY ROAD
Practice Address - Street 2:SUITE 122
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-772-5437
Practice Address - Fax:541-857-2852
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20373208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150070Medicaid
5403482OtherAETNA
838122000OtherBLUE CROSS OF OR
838122000OtherBLUE CROSS OF OR