Provider Demographics
NPI:1013962273
Name:JOHNSON, DIANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PINE AVE
Mailing Address - Street 2:#19
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:562-856-0389
Practice Address - Street 1:65 PINE AVE
Practice Address - Street 2:#19
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4718
Practice Address - Country:US
Practice Address - Phone:714-402-4685
Practice Address - Fax:562-856-0389
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62317207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA810000525OtherGOOD SAM RAILROAD
CA00G623170OtherCALOPTIMA
CAG62317OtherBLUE CROSS
CA00G623170OtherBLUE SHIELD
CA00G623170Medicaid
CAWG62317NMedicare Oscar/Certification
CA810000525OtherGOOD SAM RAILROAD