Provider Demographics
NPI:1831281013
Name:JOHNSON, ROGER ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S JOHNSON
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291
Mailing Address - Country:US
Mailing Address - Phone:559-734-1171
Mailing Address - Fax:559-734-6849
Practice Address - Street 1:308 S JOHNSON
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-734-1171
Practice Address - Fax:559-734-6849
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1217213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3974531Medicaid
ZZZ82498ZMedicare ID - Type Unspecified
CA3974531Medicaid
CA0674340001Medicare NSC