Provider Demographics
NPI:1689785925
Name:JOHNSON, PAUL W (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:# 234
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-978-0178
Mailing Address - Fax:503-286-7939
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:STE 522
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-810-6555
Practice Address - Fax:503-286-7939
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDO280842081S0010X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8467474Medicaid
WA8863014Medicare PIN
WA8467474Medicaid