MEDICARE: THEODORE J JOHNSON LMP

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	174400000X	Specialist	MA00010180	WA

General Provider Information

NPI Number	:	1982722625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE J JOHNSON LMP

Provider Business Mailing Address
First Line	:	2132 44TH AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-2102
Country	:	US
Telephone Number	:	206-261-0160
Fax Number	:	206-937-1933

Provider Business Practice Location Address
First Line	:	2132 44TH AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-2102
Country	:	US
Telephone Number	:	206-261-0160
Fax Number	:	206-937-1933

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	04/08/2009

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