Provider Demographics
NPI:1710957055
Name:JOHNSON, LEAH J (MD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 SW BARNES RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6608
Mailing Address - Country:US
Mailing Address - Phone:503-292-9108
Mailing Address - Fax:503-292-0346
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-4830
Practice Address - Fax:503-216-4850
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR185332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165012Medicaid
OR116765Medicare ID - Type Unspecified
OR165012Medicaid