Provider Demographics
NPI:1639136294
Name:JOHNSON, ANTOINE D (MD)
Entity type:Individual
Prefix:DR
First Name:ANTOINE
Middle Name:D
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:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0063
Mailing Address - Country:US
Mailing Address - Phone:360-538-7292
Mailing Address - Fax:360-533-2566
Practice Address - Street 1:105 W. 4TH STREET
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-538-7292
Practice Address - Fax:360-533-7135
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8270787Medicaid
WA8270787Medicaid
H02119Medicare UPIN