Provider Demographics
NPI:1568487973
Name:JOHNSON, ROY (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
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 1:28743 VALLEY CENTER RD STE B
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-6530
Mailing Address - Country:US
Mailing Address - Phone:760-749-0824
Mailing Address - Fax:760-749-2189
Practice Address - Street 1:28743 VALLEY CENTER RD STE B
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-6530
Practice Address - Country:US
Practice Address - Phone:760-749-0824
Practice Address - Fax:760-749-2189
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46164Medicare UPIN
CAP00304419Medicare ID - Type UnspecifiedMEDICARE RAILROAD