Provider Demographics
NPI:1518988005
Name:JOHNSON, VANCE ZACHARY (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:ZACHARY
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 1:27475 YNEZ RD # 295
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4612
Mailing Address - Country:US
Mailing Address - Phone:951-894-5000
Mailing Address - Fax:951-296-1098
Practice Address - Street 1:28078 BAXTER ROAD
Practice Address - Street 2:SUITE 128
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1402
Practice Address - Country:US
Practice Address - Phone:951-894-5000
Practice Address - Fax:951-296-1098
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61529208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A615291Medicare PIN
CAG92208Medicare UPIN