Provider Demographics
NPI:1053530634
Name:JOHNSON, ALEXANDER HERBERT (LMT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:HERBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5847 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3669
Mailing Address - Country:US
Mailing Address - Phone:503-382-9653
Mailing Address - Fax:
Practice Address - Street 1:5847 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3669
Practice Address - Country:US
Practice Address - Phone:503-382-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist