Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 1716 | OK |
NPI | 1013937713 |
---|---|
Provider Name | Dr. Clarence Michael Johnson |
First Address | Claremore, OK 74018-0368 |
Second Address | Tulsa, OK 74127-9015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 13/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100088070A | (05) | OK |
E09820 | (02) | OK |