Provider Demographics
NPI:1790977502
Name:JOHNSON, STACI R (MD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:R
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4550 EUCALYPTUS AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-9215
Mailing Address - Country:US
Mailing Address - Phone:310-629-8989
Mailing Address - Fax:
Practice Address - Street 1:4550 EUCALYPTUS AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9215
Practice Address - Country:US
Practice Address - Phone:310-629-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA858952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry