Basic Information
| Provider Information | |||||||||
| NPI: | 1699774877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JENNINGS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977090670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788376 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 SW SIMPSON AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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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 | 207Q00000X | MD13627 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 284323 | 05 | OR | MEDICAID |