Provider Demographics
NPI:1891780029
Name:JOHNSON, FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1200 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5868
Practice Address - Country:US
Practice Address - Phone:307-352-8350
Practice Address - Fax:307-352-8178
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028913207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100345950Medicaid
WY314470OtherBSWY
WY605960009OtherFBL
WY123610500Medicaid
WY123610500Medicaid
IN496650 BBMedicare PIN
WY314470OtherBSWY
WYP00366311Medicare PIN