Healthcare Provider Details

I. General information

NPI: 1609102698
Provider Name (Legal Business Name): TREVOR RUSSELL JOHNSON OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 SANTA FE DR STE 301
ENCINITAS CA
92024-5140
US

IV. Provider business mailing address

6619 BELL BLUFF AVE
SAN DIEGO CA
92119-1148
US

V. Phone/Fax

Practice location:
  • Phone: 760-633-4700
  • Fax: 760-635-4344
Mailing address:
  • Phone: 619-746-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberOTC 09-0802
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: