Provider Demographics
NPI:1578962825
Name:CRAIG R. JOHNSON, M.D., INC.
Entity Type:Organization
Organization Name:CRAIG R. JOHNSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-449-4494
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-0730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:SUITE 292
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2412
Practice Address - Country:US
Practice Address - Phone:626-449-4494
Practice Address - Fax:626-449-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB228007Medicare PIN