MEDICARE: DR. JOHNNIE HAM 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
1	208D00000X	General Practice Physician	A90443	CA
2	207V00000X	Obstetrics & Gynecology Physician	A90443	CA

General Provider Information

NPI Number	:	1982687430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHNNIE HAM M.D.

Provider Business Mailing Address
First Line	:	1677 SHELL BEACH RD STE 101
Second Line	:
City	:	SHELL BEACH
State	:	CA
Zip	:	93449-1930
Country	:	US
Telephone Number	:	805-201-9135
Fax Number	:	805-201-9134

Provider Business Practice Location Address
First Line	:	1677 SHELL BEACH RD STE 101
Second Line	:
City	:	SHELL BEACH
State	:	CA
Zip	:	93449-1930
Country	:	US
Telephone Number	:	805-201-9135
Fax Number	:	805-201-9134

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	04/26/2019

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