Provider Demographics
NPI:1255950291
Name:JOHNSON, TRAVIS ZACHARY (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ZACHARY
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14350 MERIDIAN PKWY # 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92518-3035
Mailing Address - Country:US
Mailing Address - Phone:951-827-7669
Mailing Address - Fax:
Practice Address - Street 1:14350 MERIDIAN PKWY # 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92518-3035
Practice Address - Country:US
Practice Address - Phone:951-827-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1767552084P0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry