Healthcare Provider Details

I. General information

NPI: 1396144507
Provider Name (Legal Business Name): CONSTANCE JOHANSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 CROISAN CREEK RD S
SALEM OR
97302-9474
US

IV. Provider business mailing address

3959 CROISAN CREEK RD S
SALEM OR
97302-9474
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-5363
  • Fax:
Mailing address:
  • Phone: 503-364-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD13797
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD13797
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: