Healthcare Provider Details

I. General information

NPI: 1982929329
Provider Name (Legal Business Name): JAMES AVERY JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8660 SUNRISE LN
LA MESA CA
91941-5534
US

IV. Provider business mailing address

8660 SUNRISE LN
LA MESA CA
91941-5534
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-6875
  • Fax: 619-460-4047
Mailing address:
  • Phone: 619-460-6875
  • Fax: 619-460-4047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG21631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: