Provider Demographics
NPI:1518221894
Name:JOHNSON, BETH HAGERTY (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:HAGERTY
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 1:7090 MIRATECH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3109
Mailing Address - Country:US
Mailing Address - Phone:858-304-6440
Mailing Address - Fax:
Practice Address - Street 1:7090 MIRATECH DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3109
Practice Address - Country:US
Practice Address - Phone:858-304-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101255655208000000X
390200000X
CAA161343208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program