Basic Information
| Provider Information | |||||||||
| NPI: | 1184623902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 990 SYLVAN WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604793657 | ||||||||
| FaxNumber: | 3603737616 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 SYLVAN WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604793657 | ||||||||
| FaxNumber: | 3603737616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00023534 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 46013 | 01 | WA | VICTIMS OF CRIME | OTHER | 050039619 | 01 | WA | RAILROAD MEDICARE | OTHER | 91084721504 | 01 | WA | KPS | OTHER | JO3238 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 1015023 | 05 | WA | MEDICAID | 910847215 | 01 | WA | PREMERA BLUE CROSS | OTHER | 016487001 | 01 | WA | GROUP HEALTH CORP | OTHER | 46013 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 910847215 | 01 | WA | UNIFORM MEDICAL | OTHER |