Provider Demographics
NPI:1497942106
Name:JOHNSON, PENNY ROUMANIS (MD)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:ROUMANIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 WESTWOOD BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5648
Mailing Address - Country:US
Mailing Address - Phone:310-943-8400
Mailing Address - Fax:310-923-9912
Practice Address - Street 1:11411 BROOKSHIRE AVE STE 101
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5008
Practice Address - Country:US
Practice Address - Phone:562-869-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1210832085R0202X
MI43010906832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA121083OtherCALIFORNIA MEDICAL BOARD