Healthcare Provider Details

I. General information

NPI: 1598299109
Provider Name (Legal Business Name): HEIDI JOHNG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11790 SW BARNES RD STE 120
PORTLAND OR
97225-5938
US

IV. Provider business mailing address

PO BOX 9576
BELFAST ME
04915-9576
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-9340
  • Fax: 503-200-5499
Mailing address:
  • Phone: 503-297-9340
  • Fax: 503-200-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD214544
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: