Healthcare Provider Details

I. General information

NPI: 1356570055
Provider Name (Legal Business Name): MARTA S JOHNSON-MITCHELL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 01/04/2025
Certification Date: 01/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 NE REVERE AVE STE 200
BEND OR
97701-4192
US

IV. Provider business mailing address

711 MEDFORD CTR PMB 415
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-7973
  • Fax: 541-508-7968
Mailing address:
  • Phone: 541-774-5808
  • Fax: 541-732-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101018239
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number57247
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberDO174428
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: