Basic Information
Provider Information | |||||||||
NPI: | 1417931486 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | FOLKE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 94220 4TH ST | ||||||||
Address2: |   | ||||||||
City: | GOLD BEACH | ||||||||
State: | OR | ||||||||
PostalCode: | 974447756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412473000 | ||||||||
FaxNumber: | 5412473101 | ||||||||
Practice Location | |||||||||
Address1: | 500 5TH ST | ||||||||
Address2: |   | ||||||||
City: | BROOKINGS | ||||||||
State: | OR | ||||||||
PostalCode: | 974159702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414122000 | ||||||||
FaxNumber: | 5414122081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2005 | ||||||||
LastUpdateDate: | 08/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | M10784 | ID | Y |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | MD11692 | OR | N |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 808457000 | 05 | ID |   | MEDICAID | P00809334 | 01 | ID | MCRR | OTHER | 008909 | 05 | OR |   | MEDICAID | 93-0937095 | 01 | OR | CURRY HEALTH DISTRICT TAX I.D. | OTHER |