Provider Demographics
NPI:1386984805
Name:JOHNSON, EUGENE R (EDD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 GAME FARM RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-5100
Mailing Address - Country:US
Mailing Address - Phone:509-649-4707
Mailing Address - Fax:
Practice Address - Street 1:676 GAME FARM RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-5100
Practice Address - Country:US
Practice Address - Phone:509-649-4707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA267441D171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor