Provider Demographics
NPI:1306372537
Name:JOHNSON, CEDRIC II
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:JOHNSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GLEN COVE PKWY APT 1707
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7179
Mailing Address - Country:US
Mailing Address - Phone:831-737-8023
Mailing Address - Fax:
Practice Address - Street 1:1201 GLEN COVE PKWY APT 1707
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7179
Practice Address - Country:US
Practice Address - Phone:831-737-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable