Provider Demographics
NPI:1073695557
Name:GARY R JOHNSON MD, INC
Entity Type:Organization
Organization Name:GARY R JOHNSON MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-754-1851
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-0580
Mailing Address - Country:US
Mailing Address - Phone:209-754-1851
Mailing Address - Fax:209-754-0231
Practice Address - Street 1:588 W ST CHARLES
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-754-1851
Practice Address - Fax:209-754-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27755173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G277550Medicaid
CA1114013513OtherINDIVIDUAL NPI
CAZZZ01445ZMedicare ID - Type UnspecifiedMEDICARE
CA1114013513OtherINDIVIDUAL NPI