1649481763 NPI number — NEIL G. JOHNSON, M.D. INC.

Table of content: (NPI 1649481763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649481763 NPI number — NEIL G. JOHNSON, M.D. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEIL G. JOHNSON, M.D. 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:
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:
1649481763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92427-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-881-6427
Provider Business Mailing Address Fax Number:
909-887-8708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18300 US HIGHWAY 18
Provider Second Line Business Practice Location Address:
C/O ST. MARY MEDICAL CENTER
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-881-6427
Provider Business Practice Location Address Fax Number:
909-887-8708
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-881-6427

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  G20232 , 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: ZZZ13874Z . This is a "NHIC/NCA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ13874Z . This is a "MEDICARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0079600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ54436Z . This is a "BLUE SHIELD PROVIDER #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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