Provider Demographics
NPI:1780635920
Name:WINOTO, JOHAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:WINOTO
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 1:777 CAMPUS COMMONS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-8309
Mailing Address - Country:US
Mailing Address - Phone:916-929-8564
Mailing Address - Fax:916-929-5963
Practice Address - Street 1:777 CAMPUS COMMONS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-8309
Practice Address - Country:US
Practice Address - Phone:916-929-8564
Practice Address - Fax:916-929-5963
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090745207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015060Medicaid
P00981485OtherRAILROAD MEDICARE
CAZZZ92828ZMedicare PIN