Provider Demographics
NPI:1659487395
Name:JOHNSON, MATTHEW T (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
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 1:1261 TRAVIS BLVD
Mailing Address - Street 2:STE 320
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4897
Mailing Address - Country:US
Mailing Address - Phone:707-423-2506
Mailing Address - Fax:707-425-4236
Practice Address - Street 1:1261 TRAVIS BLVD
Practice Address - Street 2:STE 320
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4897
Practice Address - Country:US
Practice Address - Phone:707-423-2506
Practice Address - Fax:707-425-4236
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38149207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAJ1871501OtherDEA
00G381490Medicare PIN
00G381492Medicare PIN
A47376Medicare UPIN