1912364175 NPI number — STEPHANE E. JOHNSON, MD, P.C.

Table of content: (NPI 1912364175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912364175 NPI number — STEPHANE E. JOHNSON, MD, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHANE E. JOHNSON, MD, P.C.
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:
1912364175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41593 WINCHESTER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92590-4860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-387-2676
Provider Business Mailing Address Fax Number:
888-882-0485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28078 BAXTER RD
Provider Second Line Business Practice Location Address:
SUITE 228
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-387-2676
Provider Business Practice Location Address Fax Number:
888-882-0485
Provider Enumeration Date:
01/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
STEPHANE
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PSYCHIATRIST
Authorized Official Telephone Number:
951-387-2676

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  A100636 , 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: A100636 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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