Healthcare Provider Details

I. General information

NPI: 1033521414
Provider Name (Legal Business Name): KYLE ERIC JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 12/22/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39400 PASEO PADRE PKWY
FREMONT CA
94538-2310
US

IV. Provider business mailing address

39400 PASEO PADRE PKWY
FREMONT CA
94538-2310
US

V. Phone/Fax

Practice location:
  • Phone: 510-248-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD182183
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA156544
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number29136
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberA156544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: