Healthcare Provider Details

I. General information

NPI: 1033268404
Provider Name (Legal Business Name): GARY A. JOHNSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 E POWELL BLVD
GRESHAM OR
97030-7609
US

IV. Provider business mailing address

417 E POWELL BLVD
GRESHAM OR
97030-7609
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-2517
  • Fax: 503-667-3239
Mailing address:
  • Phone: 503-665-2517
  • Fax: 503-667-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number22894
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number22894
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: