1053395848 NPI number — BERT JAY JOHNS III MD

Table of content: BERT JAY JOHNS III MD (NPI 1053395848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053395848 NPI number — BERT JAY JOHNS III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNS
Provider First Name:
BERT
Provider Middle Name:
JAY
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053395848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 SULLIVAN AVE
Provider Second Line Business Mailing Address:
SUITE 507
Provider Business Mailing Address City Name:
DALY CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94015-2225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-994-9936
Provider Business Mailing Address Fax Number:
650-994-2016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 SULLIVAN AVE
Provider Second Line Business Practice Location Address:
SUITE 507
Provider Business Practice Location Address City Name:
DALY CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94015-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-994-9936
Provider Business Practice Location Address Fax Number:
650-994-2016
Provider Enumeration Date:
12/05/2005

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: 208600000X , with the licence number:  G62546 , 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)

  • Identifier: 00G625460 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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