Provider Demographics
NPI:1013937713
Name:JOHNSON, CLARENCE MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:C. MICHAEL
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74018-0368
Mailing Address - Country:US
Mailing Address - Phone:918-343-6100
Mailing Address - Fax:918-341-6363
Practice Address - Street 1:802 S JACKSON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9015
Practice Address - Country:US
Practice Address - Phone:918-599-4477
Practice Address - Fax:918-599-4479
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1716208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088070AMedicaid
OKE09820Medicare UPIN
OKOK7000325Medicare PIN