Provider Demographics
NPI:1023024023
Name:JOHNSON, MARK S (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17251 17TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1963
Mailing Address - Country:US
Mailing Address - Phone:714-832-2273
Mailing Address - Fax:714-832-2272
Practice Address - Street 1:17251 17TH ST STE A
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1963
Practice Address - Country:US
Practice Address - Phone:714-832-2273
Practice Address - Fax:714-832-2272
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC11750Medicare ID - Type Unspecified