Provider Demographics
NPI:1770683658
Name:JOHNSON, LIBRE (MD)
Entity Type:Individual
Prefix:DR
First Name:LIBRE
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 1:2240 MERCURY WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5413
Mailing Address - Country:US
Mailing Address - Phone:707-570-3303
Mailing Address - Fax:
Practice Address - Street 1:2240 MERCURY WAY FL 3
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5413
Practice Address - Country:US
Practice Address - Phone:707-570-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-01001207Q00000X
CAA76860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3114543Medicaid
4311821Medicare PIN