Provider Demographics
NPI:1134960446
Name:JOHNSON, CALEB MATTHEW
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:MATTHEW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6836
Mailing Address - Country:US
Mailing Address - Phone:859-432-2438
Mailing Address - Fax:
Practice Address - Street 1:2818 CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-4059
Practice Address - Country:US
Practice Address - Phone:405-701-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant