Provider Demographics
NPI:1548978018
Name:JOHNSON, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
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 1156
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-1156
Mailing Address - Country:US
Mailing Address - Phone:405-345-1602
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 72ND ST STE 112D
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5931
Practice Address - Country:US
Practice Address - Phone:405-345-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator