Provider Demographics
NPI:1568903888
Name:JOHNSON, MAXWELL BATES (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:BATES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 MONTEREY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3157
Mailing Address - Country:US
Mailing Address - Phone:323-202-5765
Mailing Address - Fax:
Practice Address - Street 1:1510 SAN PABLO ST STE 415
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5403
Practice Address - Country:US
Practice Address - Phone:323-442-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA159221208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty