Provider Demographics
NPI:1003141318
Name:JOHNSEN, CLAYTON GARY (DPM)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:GARY
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5130
Mailing Address - Country:US
Mailing Address - Phone:909-886-3668
Mailing Address - Fax:909-886-5542
Practice Address - Street 1:1762 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5130
Practice Address - Country:US
Practice Address - Phone:909-886-3668
Practice Address - Fax:909-886-5542
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4834213E00000X
WAPO60139080213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB220721OtherMEDICARE PTAN