Provider Demographics
NPI:1760735039
Name:JOHNSON, MATTHEW DAVID
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4011
Mailing Address - Country:US
Mailing Address - Phone:509-540-5402
Mailing Address - Fax:
Practice Address - Street 1:412 E SPOKANE FALLS BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2131
Practice Address - Country:US
Practice Address - Phone:509-358-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR 60185957390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program