Provider Demographics
NPI:1639332315
Name:JOHNSON, EBUNOLUWA OMOTOLA (MD)
Entity Type:Individual
Prefix:
First Name:EBUNOLUWA
Middle Name:OMOTOLA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OMOTOLA
Other - Middle Name:EBUNOLUWA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11677 GOSHEN AVE
Mailing Address - Street 2:#312
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6291
Mailing Address - Country:US
Mailing Address - Phone:415-577-8737
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:818-364-3107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112523207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA112523OtherMEDICAL LICENSE