Provider Demographics
NPI:1780010603
Name:JOHNSON, CONNOR VANDERVEER (MD)
Entity Type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:VANDERVEER
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 1:2100 POWELL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1872
Mailing Address - Country:US
Mailing Address - Phone:510-851-7501
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST STE 400
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1872
Practice Address - Country:US
Practice Address - Phone:510-851-7501
Practice Address - Fax:510-851-7446
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138799207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALICENSEOtherA138799