Healthcare Provider Details

I. General information

NPI: 1699774877
Provider Name (Legal Business Name): PAUL JENNINGS JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 SW SIMPSON AVE SUITE 300
BEND OR
97702-3599
US

IV. Provider business mailing address

PO BOX 670
BEND OR
97709-0670
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-7741
  • Fax: 541-278-8376
Mailing address:
  • Phone: 541-389-7741
  • Fax: 541-278-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD13627
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: