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NPI Code Detail

MEDICARE: BETH HAGERTY JOHNSON M.D.

MEDICARE: BETH HAGERTY JOHNSON M.D.
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
1208000000XPediatrics Physician0101255655VA
2390200000XStudent in an Organized Health Care Education/Training Program
3208000000XPediatrics PhysicianA161343CA

General Provider Information

NPI Number : 1518221894
Entity Type Code : Individual
Provider Name (Legal Business Name) : BETH HAGERTY JOHNSON M.D.
Provider Business Mailing Address
First Line : 7090 MIRATECH DR
Second Line :
City : SAN DIEGO
State : CA
Zip : 92121-3109
Country : US
Telephone Number : 858-304-6440
Fax Number :
Provider Business Practice Location Address
First Line : 7090 MIRATECH DR
Second Line :
City : SAN DIEGO
State : CA
Zip : 92121-3109
Country : US
Telephone Number : 858-304-6440
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/01/2012
Last Update Date : 08/19/2019

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