Provider Demographics
NPI:1366430084
Name:JOHENK, PAUL DAVID (DO)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DAVID
Last Name:JOHENK
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6401
Practice Address - Fax:505-368-6431
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4190207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41639529Medicaid
NMB3824Medicaid
AZ696388Medicaid
NMB3824Medicaid
320059Medicare Oscar/Certification
AZ696388Medicaid