Provider Demographics
NPI:1619949187
Name:JOHNSON, LYNN ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1409
Mailing Address - Country:US
Mailing Address - Phone:209-464-7367
Mailing Address - Fax:209-464-1801
Practice Address - Street 1:1205 N HUNTER ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1409
Practice Address - Country:US
Practice Address - Phone:209-464-7367
Practice Address - Fax:209-464-1801
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1406213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73253ZMedicaid
CAE1406OtherSTATE LICENSE
CAE1406OtherSTATE LICENSE
T10941Medicare UPIN