Provider Demographics
NPI:1609372697
Name:JOHNSON, CORY (MD)
Entity Type:Individual
Prefix:
First Name:CORY
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 1:995 POTRERO AVE # WARD83
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-2859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:628-246-8458
Practice Address - Street 1:995 POTRERO AVE BLDG 80-83
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2859
Practice Address - Country:US
Practice Address - Phone:628-206-5252
Practice Address - Fax:628-206-7505
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
CAA166923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health