Provider Demographics
NPI:1205893781
Name:JOHNSON, GORDON RAY (DO)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:RAY
Last Name:JOHNSON
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 1:3906 LILLIE AVE.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-4432
Mailing Address - Country:US
Mailing Address - Phone:563-391-3309
Mailing Address - Fax:563-391-3630
Practice Address - Street 1:3906 LILLIE AVE.
Practice Address - Street 2:SUITE 1
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-4432
Practice Address - Country:US
Practice Address - Phone:563-391-3309
Practice Address - Fax:563-391-3630
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1926207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D46563Medicare UPIN
19634Medicare ID - Type Unspecified