1750647319 NPI number — LEONIDAS A. JOHNSON, O.D., A PROFESSIONAL CORPORATION

Table of content: (NPI 1750647319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750647319 NPI number — LEONIDAS A. JOHNSON, O.D., A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEONIDAS A. JOHNSON, O.D., A PROFESSIONAL CORPORATION
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:
1750647319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4434
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIAMOND BAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91765-0434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-828-7798
Provider Business Mailing Address Fax Number:
714-828-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8615 KNOTT AVE.
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
BUENA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90620-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-828-7798
Provider Business Practice Location Address Fax Number:
714-828-7190
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
LEONIDAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-828-7798

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  8254 , 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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