Provider Demographics
NPI:1982929329
Name:JOHNSON, JAMES AVERY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:AVERY
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 1:8660 SUNRISE LN
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-5534
Mailing Address - Country:US
Mailing Address - Phone:619-460-6875
Mailing Address - Fax:619-460-4047
Practice Address - Street 1:8660 SUNRISE LN
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5534
Practice Address - Country:US
Practice Address - Phone:619-460-6875
Practice Address - Fax:619-460-4047
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery