MEDICARE: DR. KEVIN RAYMOND JOHNSON I M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	MD16564	OR
2	2086S0129X	Vascular Surgery Physician	MD16564	OR
3	208C00000X	Colon & Rectal Surgery Physician	MD16564	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00924574	OTHER	OR	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750387049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN RAYMOND JOHNSON I M.D.

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:	503-215-6494
Fax Number	:	503-215-6644

Provider Business Practice Location Address
First Line	:	1510 DIVISION ST
Second Line	:	STE 210
City	:	OREGON CITY
State	:	OR
Zip	:	97045-1599
Country	:	US
Telephone Number	:	503-723-6525
Fax Number	:	503-723-6508

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	06/27/2011

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Directions to “ DR. KEVIN RAYMOND JOHNSON I M.D.” Practice Location

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