Provider Demographics
NPI:1851407282
Name:JOHNSON, CORY T (MD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:T
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 1:2301 MOUNTAIN VIEW BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1137
Mailing Address - Country:US
Mailing Address - Phone:541-884-6374
Mailing Address - Fax:541-884-6731
Practice Address - Street 1:2301 MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1137
Practice Address - Country:US
Practice Address - Phone:541-884-6374
Practice Address - Fax:541-884-6731
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24075174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286362Medicaid
ORH72592Medicare UPIN
OR472592Medicare UPIN
OR286362Medicaid