Provider Demographics
NPI:1215043229
Name:JOHANSON, GARY ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ANDREW
Last Name:JOHANSON
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 1:500 DOYLE PARK DR
Mailing Address - Street 2:SUITE G04
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4558
Mailing Address - Country:US
Mailing Address - Phone:707-573-8984
Mailing Address - Fax:707-573-0982
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:SUITE G04
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4558
Practice Address - Country:US
Practice Address - Phone:707-573-8984
Practice Address - Fax:707-573-0982
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32438207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680479679OtherTAX ID
CA33-0185031OtherTAX ID# AS OF 9/1/2010
CAA45151Medicare UPIN
CA00G324380Medicare ID - Type Unspecified