Healthcare Provider Details

I. General information

NPI: 1780919282
Provider Name (Legal Business Name): WALTER KIP JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: W. KIP JOHNSON M.D.

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PRESTON AVE
IONE CA
95640-9158
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-6144
  • Fax:
Mailing address:
  • Phone: 209-754-6262
  • Fax: 209-754-6275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG32232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: