Basic Information
| Provider Information | |||||||||
| NPI: | 1841306156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ELLIS | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 821350 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986820030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606875221 | ||||||||
| FaxNumber: | 3606660466 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 2ND ST | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986748486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602258911 | ||||||||
| FaxNumber: | 3602258547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00023663 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 105322 | 01 | WA | DEPT OF L&I | OTHER | 016647 | 05 | OR | MEDICAID | 1087113 | 05 | WA | MEDICAID |