Provider Demographics
NPI:1609102698
Name:JOHNSON, TREVOR RUSSELL (OTC)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6619 BELL BLUFF AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1148
Mailing Address - Country:US
Mailing Address - Phone:619-746-9194
Mailing Address - Fax:
Practice Address - Street 1:320 SANTA FE DR STE 301
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5140
Practice Address - Country:US
Practice Address - Phone:760-633-4700
Practice Address - Fax:760-635-4344
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OTC 09-0802246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant