Provider Demographics
NPI:1629397153
Name:JOHNSON, MICHAEL AUSTIN (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:AUSTIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 STOCKTON BLVD
Mailing Address - Street 2:UC DAVIS MEDICAL CENTER
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:608-712-7152
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:UC DAVIS MEDICAL CENTER
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:608-712-7152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL-3588207P00000X
CO52351207P00000X
CA130811207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO023892OtherKAISER COMERCIAL NUMBER
CO16426541Medicaid
CO316941YK5YMedicare PIN