Provider Demographics
NPI:1700046737
Name:JOHNSON, JEREMY J (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
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 1:920 STANTON L YOUNG BLVD # 2140
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5020
Mailing Address - Country:US
Mailing Address - Phone:405-271-6308
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD # 2140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5020
Practice Address - Country:US
Practice Address - Phone:405-271-6308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-170992086S0120X, 208600000X
OK26424208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery