Healthcare Provider Details

I. General information

NPI: 1689785925
Provider Name (Legal Business Name): PAUL W JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST STE 522
PORTLAND OR
97210-3033
US

IV. Provider business mailing address

3439 NE SANDY BLVD # 234
PORTLAND OR
97232-1959
US

V. Phone/Fax

Practice location:
  • Phone: 503-810-6555
  • Fax: 503-286-7939
Mailing address:
  • Phone: 503-978-0178
  • Fax: 503-286-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberDO28084
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberDO28084
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: