=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578807111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRY RICHARD JOHNSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2012
-----------------------------------------------------
Last Update Date | 11/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13405 SHORELINE DR SE
-----------------------------------------------------
City | OLALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98359-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-857-7348
-----------------------------------------------------
Fax | 253-857-7363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13405 SHORELINE DR SE
-----------------------------------------------------
City | OLALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98359-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-857-7348
-----------------------------------------------------
Fax | 253-857-7363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD 00018130
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------