=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003967456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLIFFORD JOHN JOHNSON DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7320 179TH ST SW
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98026-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-743-5160
-----------------------------------------------------
Fax | 425-743-5160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7320 179TH ST SW
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98026-5534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-743-5160
-----------------------------------------------------
Fax | 425-743-5160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 691
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------