Healthcare Provider Details

I. General information

NPI: 1407876063
Provider Name (Legal Business Name): DEREK JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 JOHN MUIR PKWY STE 105
BRENTWOOD CA
94513-5183
US

IV. Provider business mailing address

2350 W EL CAMINO REAL FL 2
MOUNTAIN VIEW CA
94040-6203
US

V. Phone/Fax

Practice location:
  • Phone: 925-513-2483
  • Fax: 925-513-4957
Mailing address:
  • Phone: 925-513-2483
  • Fax: 925-513-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: