Provider Demographics
NPI:1346308756
Name:JOHNSON, VEASSA GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:VEASSA
Middle Name:GAIL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 S FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3159
Mailing Address - Country:US
Mailing Address - Phone:323-232-2601
Mailing Address - Fax:323-232-1924
Practice Address - Street 1:4760 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3159
Practice Address - Country:US
Practice Address - Phone:323-232-2601
Practice Address - Fax:323-232-1924
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG032489174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91449Medicare UPIN