1548278534 NPI number — KARL JOHSENS MD & DRUSILLA LDH LEE MD INC

Table of content: (NPI 1548278534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548278534 NPI number — KARL JOHSENS MD & DRUSILLA LDH LEE MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KARL JOHSENS MD & DRUSILLA LDH LEE MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1548278534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1595 SOQUEL DR STE 340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95065-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-425-1279
Provider Business Mailing Address Fax Number:
831-425-3500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1595 SOQUEL DR STE 340
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95065-1722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-425-1279
Provider Business Practice Location Address Fax Number:
831-425-3500
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHSEN
Authorized Official First Name:
KARL
Authorized Official Middle Name:
KNUDSEN
Authorized Official Title or Position:
PHYSICIAN PRESIDENT
Authorized Official Telephone Number:
831-425-1279

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G084030 , 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: 00G840300 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: CH1649 . This is a "GROUP MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110208332 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00G840300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ62382Z . This is a "GROUP BLUE SHIELD CEDAR M" identifier . This identifiers is of the category "OTHER".
  • Identifier: G054030 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 610730500 . This is a "US DEPT OF LABOR OFFICE O" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0090740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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