Provider Demographics
NPI:1669671673
Name:JOHNSON, VIRGINIA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 15TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2756
Mailing Address - Country:US
Mailing Address - Phone:310-576-2505
Mailing Address - Fax:310-576-2501
Practice Address - Street 1:1448 15TH ST STE 207
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2756
Practice Address - Country:US
Practice Address - Phone:310-576-2505
Practice Address - Fax:310-576-2501
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7958204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM