Provider Demographics
NPI:1023171071
Name:JOHNSON, JAY D (DO)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 LAKE OTIS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5234
Mailing Address - Country:US
Mailing Address - Phone:907-212-6900
Mailing Address - Fax:
Practice Address - Street 1:3801 LAKE OTIS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5234
Practice Address - Country:US
Practice Address - Phone:907-212-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40282080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200001850AMedicaid