Provider Demographics
NPI:1962462358
Name:JOHNSON, RODNEY ELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:ELLIS
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 1:25714 38TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-9335
Mailing Address - Country:US
Mailing Address - Phone:360-770-1854
Mailing Address - Fax:
Practice Address - Street 1:328 S STILLAGUAMISH AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1660
Practice Address - Country:US
Practice Address - Phone:360-435-6641
Practice Address - Fax:360-618-7663
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22830207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2189829Medicaid
IA2189829Medicaid
A01915Medicare UPIN