Provider Demographics
NPI:1982023479
Name:JOHNSON, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
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 1:5 CENTERPOINTE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8661
Mailing Address - Country:US
Mailing Address - Phone:503-606-6635
Mailing Address - Fax:581-333-1291
Practice Address - Street 1:5 CENTERPOINTE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8651
Practice Address - Country:US
Practice Address - Phone:503-606-6355
Practice Address - Fax:503-404-4555
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9601928-12052084P0800X
ORMD1874902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry