Provider Demographics
NPI:1184836066
Name:J.R. JOHNSON, M.D., INC
Entity type:Organization
Organization Name:J.R. JOHNSON, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-218-1470
Mailing Address - Street 1:901 CALLE AMANECER
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673
Mailing Address - Country:US
Mailing Address - Phone:949-218-1470
Mailing Address - Fax:949-218-1471
Practice Address - Street 1:901 CALLE AMANECER
Practice Address - Street 2:STE 100
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-218-1470
Practice Address - Fax:949-218-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69427261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF22693Medicare UPIN
CAG69427Medicare ID - Type Unspecified