Provider Demographics
NPI:1740288976
Name:JOHNSON, MARTIN L (DC)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CANON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2612
Mailing Address - Country:US
Mailing Address - Phone:619-223-1617
Mailing Address - Fax:619-223-1618
Practice Address - Street 1:3020 CANON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2612
Practice Address - Country:US
Practice Address - Phone:619-223-1617
Practice Address - Fax:619-223-1618
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12436111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC12436Medicare ID - Type Unspecified