Provider Demographics
NPI:1881765584
Name:JOHNSON, THOMAS L JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:JOHNSON
Suffix:JR
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 1:9100 S SEPULVEDA BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4849
Mailing Address - Country:US
Mailing Address - Phone:310-674-6785
Mailing Address - Fax:310-674-2161
Practice Address - Street 1:9100 S SEPULVEDA BLVD STE 121
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4849
Practice Address - Country:US
Practice Address - Phone:310-674-6785
Practice Address - Fax:310-674-2161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41044208800000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C410441Medicaid
CAC41044AMedicare PIN
CAA88221Medicare UPIN