Provider Demographics
NPI:1710957105
Name:JOHNSEN, GREGORY D (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:JOHNSEN
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 1:9228 S MINGO RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:918-592-0999
Mailing Address - Fax:918-878-2499
Practice Address - Street 1:1265 S UTICA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4243
Practice Address - Country:US
Practice Address - Phone:918-592-0999
Practice Address - Fax:918-592-1021
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16972174400000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK110104903OtherMEDICARE RAILROAD
OKOK400770OtherMEDICARE PTAN
OKP00611405OtherMEDICARE RAILROAD
OK100254430AMedicaid
OKE86866Medicare UPIN