MEDICARE: DR. BRUCE JOHNSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	15194	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750386579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE JOHNSON MD

Provider Business Mailing Address
First Line	:	3099 RIVER RD S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-9754
Country	:	US
Telephone Number	:	503-518-1567
Fax Number	:	503-399-1229

Provider Business Practice Location Address
First Line	:	3099 RIVER RD S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-9754
Country	:	US
Telephone Number	:	503-518-1567
Fax Number	:	503-399-1229

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	10/31/2011

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Directions to “ DR. BRUCE JOHNSON MD” Practice Location

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