Provider Demographics
NPI:1437163953
Name:JOHNSON, ROBERT R (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 BRISTOL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3054
Mailing Address - Country:US
Mailing Address - Phone:949-266-3700
Mailing Address - Fax:949-266-3750
Practice Address - Street 1:3150 BRISTOL ST STE 400
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3054
Practice Address - Country:US
Practice Address - Phone:949-266-3700
Practice Address - Fax:949-266-3750
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A49082084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX56630Medicaid
CA00AX56630Medicaid
A93596Medicare UPIN