Provider Demographics
NPI:1528041076
Name:JOHNSON, N. RAGNER (MD)
Entity Type:Individual
Prefix:DR
First Name:N.
Middle Name:RAGNER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NILS
Other - Middle Name:RAGNER
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 325
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-244-0112
Mailing Address - Fax:818-244-8544
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 325
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-244-0112
Practice Address - Fax:818-244-8544
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA58740Medicare UPIN
CAG8952Medicare ID - Type Unspecified