1366517989 NPI number — CHRISTOPHER D. JOHNSON OD, PC

Table of content: (NPI 1366517989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366517989 NPI number — CHRISTOPHER D. JOHNSON OD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER D. JOHNSON OD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1366517989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
986 SE UGLOW ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-623-3538
Provider Business Mailing Address Fax Number:
503-623-8112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
986 SE UGLOW ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-3538
Provider Business Practice Location Address Fax Number:
503-623-8112
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
DOCTOR OF OPTOMETRY OWNER
Authorized Official Telephone Number:
503-623-3538

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2925ATI , 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: DC770 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 212606 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 298499 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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