Provider Demographics
NPI:1821288309
Name:JOHNSON, CHARLES RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:RICHARD
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:1334
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1720
Mailing Address - Country:US
Mailing Address - Phone:206-682-4061
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:1334
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1743
Practice Address - Country:US
Practice Address - Phone:206-682-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000085672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry