Provider Demographics
NPI:1649299173
Name:JOHNSON, MICHAEL WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
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 1:21887 SW SHERWOOD BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9412
Mailing Address - Country:US
Mailing Address - Phone:503-625-7474
Mailing Address - Fax:503-625-1688
Practice Address - Street 1:21887 SW SHERWOOD BLVD STE C
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9412
Practice Address - Country:US
Practice Address - Phone:503-625-7474
Practice Address - Fax:503-625-1688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000BHKSMMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ORC92045Medicare UPIN