Provider Demographics
NPI:1649481763
Name:NEIL G. JOHNSON, M.D. INC.
Entity type:Organization
Organization Name:NEIL G. JOHNSON, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-881-6427
Mailing Address - Street 1:PO BOX 9160
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92427-0160
Mailing Address - Country:US
Mailing Address - Phone:909-881-6427
Mailing Address - Fax:909-887-8708
Practice Address - Street 1:18300 US HIGHWAY 18
Practice Address - Street 2:C/O ST. MARY MEDICAL CENTER
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2206
Practice Address - Country:US
Practice Address - Phone:909-881-6427
Practice Address - Fax:909-887-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20232207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13874ZOtherNHIC/NCA
CAZZZ13874ZOtherMEDICARE ID
CAGR0079600Medicaid
CAZZZ54436ZOtherBLUE SHIELD PROVIDER #
CAZZZ13874ZOtherNHIC/NCA