Provider Demographics
NPI:1417191990
Name:DIANE L. JOHNSON M.D. INC
Entity Type:Organization
Organization Name:DIANE L. JOHNSON M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-402-4685
Mailing Address - Street 1:65 PINE AVE
Mailing Address - Street 2:SUITE 19
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4718
Mailing Address - Country:US
Mailing Address - Phone:714-402-4685
Mailing Address - Fax:562-856-0389
Practice Address - Street 1:65 PINE AVE
Practice Address - Street 2:SUITE 19
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4718
Practice Address - Country:US
Practice Address - Phone:714-402-4685
Practice Address - Fax:562-856-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62317207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013962273OtherINDIV . NPI
CA1013962273OtherINDIV . NPI