1104846351 NPI number — ROBERT G JOHNSON JR. M.D.

Table of content: ROBERT G JOHNSON JR. M.D. (NPI 1104846351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104846351 NPI number — ROBERT G JOHNSON JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
ROBERT
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104846351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97709-0670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-276-1700
Provider Business Mailing Address Fax Number:
541-276-6327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 SW PERKINS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-276-1700
Provider Business Practice Location Address Fax Number:
541-276-6327
Provider Enumeration Date:
07/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00040371 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD191277 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8310351 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".