Healthcare Provider Details

I. General information

NPI: 1114292034
Provider Name (Legal Business Name): DEBORAH M JOHNSON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 LIBERTY ST SE
SALEM OR
97302-4276
US

IV. Provider business mailing address

1395 LIBERTY ST SE
SALEM OR
97302-4276
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-9695
  • Fax: 503-581-3960
Mailing address:
  • Phone: 503-585-9695
  • Fax: 503-581-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD16845
License Number StateOR

VIII. Authorized Official

Name: DR. DEBORAH M JOHNSON
Title or Position: OWNER
Credential:
Phone: 503-585-9695