=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407145568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTIN T JOHNSON DPM INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2011
-----------------------------------------------------
Last Update Date | 08/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 HWY 99 N STE 201
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97520-8900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-482-4924
-----------------------------------------------------
Fax | 541-488-1732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 HWY 99 N STE 201
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97520-8900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-482-4924
-----------------------------------------------------
Fax | 541-488-1732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JUSTIN THEO JOHNSON
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 541-482-4924
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | DP00440
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------