Provider Demographics
NPI:1245311216
Name:JOHNSON, DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0459
Mailing Address - Country:US
Mailing Address - Phone:619-429-3733
Mailing Address - Fax:619-429-6457
Practice Address - Street 1:949 PALM AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1503
Practice Address - Country:US
Practice Address - Phone:619-429-3733
Practice Address - Fax:619-429-6457
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FHC70394FOtherMEDI CAL
W5740BMedicare ID - Type Unspecified