Provider Demographics
NPI:1164096434
Name:JOHNSON, TALOR
Entity Type:Individual
Prefix:
First Name:TALOR
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 245TH ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 S BRISTOL ST STE 101-103
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5751
Practice Address - Country:US
Practice Address - Phone:714-754-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016860208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics