Provider Demographics
NPI:1477682953
Name:CRAIG E. JOHNSON MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CRAIG E. JOHNSON MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-796-3498
Mailing Address - Street 1:2299 MOWRY AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1621
Mailing Address - Country:US
Mailing Address - Phone:510-796-3498
Mailing Address - Fax:510-794-4109
Practice Address - Street 1:2299 MOWRY AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1621
Practice Address - Country:US
Practice Address - Phone:510-796-3498
Practice Address - Fax:510-794-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86787207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G867870Medicaid
CAZZZ28415ZMedicare PIN
CA00G867870Medicaid