Provider Demographics
NPI:1174551295
Name:JOHNSON, MICHAEL W (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 40TH ST W
Mailing Address - Street 2:STE 100
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-564-0170
Mailing Address - Fax:253-207-4240
Practice Address - Street 1:7210 40TH ST W
Practice Address - Street 2:STE 100
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466
Practice Address - Country:US
Practice Address - Phone:253-564-0170
Practice Address - Fax:253-207-4240
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA160004OtherSTATE L&I
WA8311359Medicaid
WA8937028OtherSTATE CRIME VICTIMS
WA080188803OtherRAILROAD
WA160005OtherSTATE L&I
WAAB28985Medicare ID - Type Unspecified
WA160004OtherSTATE L&I
WAGAB2898Medicare PIN