Provider Demographics
NPI:1174508865
Name:JOHNSON, ALFRED B (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:B
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 1:240 E 13TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6234
Mailing Address - Country:US
Mailing Address - Phone:209-723-2799
Mailing Address - Fax:209-723-2984
Practice Address - Street 1:240 E 13TH ST STE C
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6234
Practice Address - Country:US
Practice Address - Phone:209-723-2799
Practice Address - Fax:209-723-2984
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184876208600000X
GA42860208600000X
MS19035208600000X
CAG88950208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41563Medicare UPIN