Provider Demographics
NPI:1649244385
Name:JOHNSON, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
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 1:473 CABRILLO ST BLDG 422
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93944-3201
Mailing Address - Country:US
Mailing Address - Phone:831-242-7990
Mailing Address - Fax:831-242-2822
Practice Address - Street 1:473 CABRILLO ST BLDG 422
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93944-3201
Practice Address - Country:US
Practice Address - Phone:831-242-7990
Practice Address - Fax:831-242-2822
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67344207Q00000X, 2083P0011X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG67344OtherMEDICAL LICENSE
562564529OtherEIN/TIN