Healthcare Provider Details

I. General information

NPI: 1013937713
Provider Name (Legal Business Name): CLARENCE MICHAEL JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: C. MICHAEL JOHNSON D.O.

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S JACKSON AVE SUITE 110
TULSA OK
74127-9015
US

IV. Provider business mailing address

PO BOX 368
CLAREMORE OK
74018-0368
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-4477
  • Fax: 918-599-4479
Mailing address:
  • Phone: 918-343-6100
  • Fax: 918-341-6363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1716
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: