Provider Demographics
NPI:1245851971
Name:JOHNSON, ALEXANDER ALIDE (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ALIDE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:097-939-7155
Mailing Address - Fax:097-643-2445
Practice Address - Street 1:8420 ASPI BLVD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3601
Practice Address - Country:US
Practice Address - Phone:509-793-9781
Practice Address - Fax:509-764-3281
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61459255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2251041Medicaid