Provider Demographics
NPI:1114013513
Name:JOHNSON, GARY RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RONALD
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:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249
Mailing Address - Country:US
Mailing Address - Phone:209-754-1851
Mailing Address - Fax:209-754-0231
Practice Address - Street 1:588 W. ST.CHARLES STREET
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27755208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G277550Medicaid
CA00G277550Medicaid
CAZZZ01445ZMedicare ID - Type Unspecified