Provider Demographics
NPI:1770596009
Name:JOHNSON, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:15200 W SUNSET BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3620
Mailing Address - Country:US
Mailing Address - Phone:310-459-7736
Mailing Address - Fax:310-230-0284
Practice Address - Street 1:15200 W SUNSET BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3620
Practice Address - Country:US
Practice Address - Phone:310-459-7736
Practice Address - Fax:310-230-0284
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G375310Medicaid
CAWG37531DMedicare PIN
CAA47133Medicare UPIN
CAWG37531CMedicare PIN