Provider Demographics
NPI:1477672046
Name:JOHNSON, RONALD M (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:M
Last Name:JOHNSON
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:PO BOX 2507
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2507
Mailing Address - Country:US
Mailing Address - Phone:619-462-5900
Mailing Address - Fax:619-462-9899
Practice Address - Street 1:5360 JACKSON DRIVE
Practice Address - Street 2:STE 100
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91943
Practice Address - Country:US
Practice Address - Phone:619-462-5900
Practice Address - Fax:619-462-9899
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19831208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G19831Medicaid
CA00G19831Medicaid
A40767Medicare UPIN