1033215488 NPI number — DR. LARISA MARIE JOHNSON-TONG O.D.

Table of content: DR. LARISA MARIE JOHNSON-TONG O.D. (NPI 1033215488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033215488 NPI number — DR. LARISA MARIE JOHNSON-TONG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON-TONG
Provider First Name:
LARISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
LARISA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033215488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4860 Y ST
Provider Second Line Business Mailing Address:
SUITE 2400
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-734-4641
Provider Business Mailing Address Fax Number:
916-565-1620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4860 Y ST
Provider Second Line Business Practice Location Address:
SUITE 2400
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-4641
Provider Business Practice Location Address Fax Number:
916-565-1620
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  12038T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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