Provider Demographics
NPI:1154370526
Name:JOHNSON, G THEODORE (MD)
Entity type:Individual
Prefix:
First Name:G
Middle Name:THEODORE
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 1:1100 OLIVE WAY
Mailing Address - Street 2:MS: M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:206-515-5886
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015190207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8128902Medicaid
WAJ449OtherINDIVIDUAL BLUE SHIELD
WA0039578OtherL&I
WA930018996OtherRAIL ROAD MEDICARE
WA930018996OtherRAIL ROAD MEDICARE
WA000142802Medicare PIN