Provider Demographics
NPI:1740274380
Name:JOHNSON, NEIL GRANT (MD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:GRANT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NEIL
Other - Middle Name:G
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
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: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:909-880-8708
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20232207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G202320Medicaid
CAZZZ13874ZMedicare PIN
CA00G202320Medicaid