Provider Demographics
NPI:1093799942
Name:W IRVING JOHNSON MD INC
Entity Type:Organization
Organization Name:W IRVING JOHNSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:IRVING
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-208-5100
Mailing Address - Street 1:418 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3302
Mailing Address - Country:US
Mailing Address - Phone:510-208-5100
Mailing Address - Fax:510-465-6810
Practice Address - Street 1:418 30TH STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3302
Practice Address - Country:US
Practice Address - Phone:510-208-5100
Practice Address - Fax:510-465-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C360880Medicaid
CA00C360880Medicaid
CA00C360880Medicare PIN