Healthcare Provider Details

I. General information

NPI: 1528122751
Provider Name (Legal Business Name): MARK A JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 QUEEN ANNE AVE N
SEATTLE WA
98109-2313
US

IV. Provider business mailing address

PO BOX 84026
SEATTLE WA
98124-8426
US

V. Phone/Fax

Practice location:
  • Phone: 206-861-8500
  • Fax: 206-861-8501
Mailing address:
  • Phone: 206-861-8500
  • Fax: 206-861-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberMD00042851
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00042851
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: