Provider Demographics
NPI:1760727614
Name:JOHNSON, HENRY STEWART
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:STEWART
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PINE AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4457
Mailing Address - Country:US
Mailing Address - Phone:562-436-9080
Mailing Address - Fax:562-435-8303
Practice Address - Street 1:115 PINE AVE
Practice Address - Street 2:SUITE 615
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4457
Practice Address - Country:US
Practice Address - Phone:562-436-9080
Practice Address - Fax:562-435-8303
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46419207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG46419OtherMEDICAL LIC NUMBER