Provider Demographics
NPI:1073671921
Name:JOHNSON, RANDY PHILLIP (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:PHILLIP
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 S COLLEGE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1302
Mailing Address - Country:US
Mailing Address - Phone:805-922-6610
Mailing Address - Fax:805-922-1226
Practice Address - Street 1:2151 S COLLEGE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1302
Practice Address - Country:US
Practice Address - Phone:805-922-6610
Practice Address - Fax:805-922-1226
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62052207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93127Medicare UPIN
CAG52032Medicare ID - Type Unspecified