Basic Information
| Provider Information | |||||||||
| NPI: | 1205965951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | DESMOND | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1508 DIVISION ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036571071 | ||||||||
| FaxNumber: | 5036573321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 DIVISION ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036571071 | ||||||||
| FaxNumber: | 5036573321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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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 | 207V00000X | MD10451 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 231514 | 05 | OR | MEDICAID |