Provider Demographics
NPI:1013163112
Name:DIANE L. JOHNSON, M.D., INC.
Entity Type:Organization
Organization Name:DIANE L. JOHNSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-402-4685
Mailing Address - Street 1:65 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4718
Mailing Address - Country:US
Mailing Address - Phone:714-402-4685
Mailing Address - Fax:818-462-0991
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:213-484-7111
Practice Address - Fax:213-207-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62317207RC0200X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG62317OtherLICENSE NUMBER