Healthcare Provider Details

I. General information

NPI: 1336108208
Provider Name (Legal Business Name): MICHELLE L JOHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST SUITE 220
GRESHAM OR
97030-8322
US

IV. Provider business mailing address

1414 NE HANCOCK ST
PORTLAND OR
97212-4440
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD25190
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: