Basic Information
| Provider Information | |||||||||
| NPI: | 1487971693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 MONTLAKE BLVD | ||||||||
| Address2: | PO BOX 50095 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981950007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
| FaxNumber: | 2065983140 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 MONTLAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065981534 | ||||||||
| FaxNumber: | 2065983140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2010 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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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 | 208100000X | MD 60301821 | WA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081S0010X | MD60301821 | WA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1487971693 | 05 | WA | MEDICAID |