Provider Demographics
NPI:1205965951
Name:JOHNSON, HAROLD DESMOND (MEDICAL DOCTOR)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:DESMOND
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 DIVISION ST
Mailing Address - Street 2:STE 205
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-657-1071
Mailing Address - Fax:503-657-3321
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:STE 205
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10451207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231514Medicaid
OR0000BHHNBMedicare ID - Type Unspecified
OR231514Medicaid