Provider Demographics
NPI:1336191063
Name:JOHNSON, CRAIG R (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E GREEN ST
Mailing Address - Street 2:SUITE 292
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2401
Mailing Address - Country:US
Mailing Address - Phone:626-449-4494
Mailing Address - Fax:626-449-4474
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:SUITE 292
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-449-4494
Practice Address - Fax:626-449-4474
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00758190OtherRAILROAD MEDICARE
CA00G722410Medicaid
CAWG72241BMedicare PIN
CAP00758190OtherRAILROAD MEDICARE
CAF67081Medicare UPIN