Provider Demographics
NPI:1487679684
Name:JOHNSON, CARL E (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:E
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 959
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-0959
Mailing Address - Country:US
Mailing Address - Phone:805-434-1375
Mailing Address - Fax:805-434-1716
Practice Address - Street 1:24 LAS PRADERAS DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7410
Practice Address - Country:US
Practice Address - Phone:805-544-7832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33572207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A335721OtherBLUE SHIELD OF CALIFORNIA
CA00A335720Medicaid
CAA27188Medicare UPIN
CA00A335720Medicaid