Healthcare Provider Details

I. General information

NPI: 1780635920
Provider Name (Legal Business Name): JOHAN WINOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 KAUSEN DR STE 103
ELK GROVE CA
95758-7178
US

IV. Provider business mailing address

1111 EXPOSITION BLVD STE 300
SACRAMENTO CA
95815-4324
US

V. Phone/Fax

Practice location:
  • Phone: 916-683-8774
  • Fax: 916-683-8777
Mailing address:
  • Phone: 916-929-8564
  • Fax: 916-929-4529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA116149
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35090745
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: