Provider Demographics
NPI:1518044791
Name:JOHNSON, MIRIAM D (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 NE 124TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4344
Mailing Address - Country:US
Mailing Address - Phone:425-899-4200
Mailing Address - Fax:425-899-4202
Practice Address - Street 1:12707 120TH AVE NE
Practice Address - Street 2:SUITE 202
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7500
Practice Address - Country:US
Practice Address - Phone:425-899-4200
Practice Address - Fax:425-899-4202
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024675174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1049154Medicaid
WAJO4111OtherREGENCE
WA1049154Medicaid