Provider Demographics
NPI:1073557708
Name:JOHNSON, MARILYN STAROBA (PT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:STAROBA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 CAMINO DE LA SIESTA STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3118
Mailing Address - Country:US
Mailing Address - Phone:619-260-0750
Mailing Address - Fax:619-260-0201
Practice Address - Street 1:5030 CAMINO DE LA SIESTA STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3118
Practice Address - Country:US
Practice Address - Phone:619-260-0750
Practice Address - Fax:619-260-0201
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT122942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT12294BMedicare PIN