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General NPI Number Information
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NPI Number | 1124362066
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Entity Type | Organization
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Legal Business Name | GORDON R JOHNSON D O P C
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 3906 LILLIE AVE SUITE 1
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City | DAVENPORT
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State | IA
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Zip | 52806-4434
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Country | US
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Telephone | 563-391-3309
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Fax |
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Provider Business Mailing Address
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Address Line | 3906 LILLIE AVE SUITE 1
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City | DAVENPORT
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State | IA
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Zip | 52806-4434
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GORDON R JOHNSON
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Credential | D.O.
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Telephone | 563-391-3309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 1926
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License Number State | IA
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