MEDICARE: ROBERT JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1457776635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT JOHNSON

Provider Business Mailing Address
First Line	:	6435 LAGO CIR
Second Line	:
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683-9249
Country	:	US
Telephone Number	:	916-342-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	6435 LAGO CIR
Second Line	:
City	:	RANCHO MURIETA
State	:	CA
Zip	:	95683-9249
Country	:	US
Telephone Number	:	916-342-5919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2014
Last Update Date	:	02/25/2014

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