Healthcare Provider Details

I. General information

NPI: 1578807111
Provider Name (Legal Business Name): HARRY RICHARD JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13405 SHORELINE DR SE
OLALLA WA
98359-9618
US

IV. Provider business mailing address

13405 SHORELINE DR SE
OLALLA WA
98359-9618
US

V. Phone/Fax

Practice location:
  • Phone: 253-857-7348
  • Fax: 253-857-7363
Mailing address:
  • Phone: 253-857-7348
  • Fax: 253-857-7363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD 00018130
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: