Healthcare Provider Details

I. General information

NPI: 1639136534
Provider Name (Legal Business Name): THOMAS MARTIN JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

2040 VISTA DE LA VINA
TEMPLETON CA
93465-8348
US

V. Phone/Fax

Practice location:
  • Phone: 877-515-8113
  • Fax: 877-538-2102
Mailing address:
  • Phone: 805-975-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG081064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: