Provider Demographics
NPI:1609050228
Name:HENRY S. JOHNSON, M.D.
Entity Type:Organization
Organization Name:HENRY S. JOHNSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-436-9080
Mailing Address - Street 1:110 W OCEAN BLVD STE 426
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4678
Mailing Address - Country:US
Mailing Address - Phone:562-436-9080
Mailing Address - Fax:
Practice Address - Street 1:110 W OCEAN BLVD STE 426
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4678
Practice Address - Country:US
Practice Address - Phone:562-436-9080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46419207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG42619Medicare PIN