Provider Demographics
NPI:1538330139
Name:JOHNSON, STEPHEN HERBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:HERBERT
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 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-760-9007
Mailing Address - Fax:949-760-8654
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-760-9007
Practice Address - Fax:949-760-8654
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38506207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92001Medicare UPIN