Healthcare Provider Details

I. General information

NPI: 1194068635
Provider Name (Legal Business Name): LAKE COUNTY ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5176 HILL RD E
LAKEPORT CA
95453-6300
US

IV. Provider business mailing address

PO BOX 5486
ORANGE CA
92863-5486
US

V. Phone/Fax

Practice location:
  • Phone: 707-262-5000
  • Fax:
Mailing address:
  • Phone: 818-550-0900
  • Fax: 505-293-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FREDERICK JOHNSON
Title or Position: PRESDIENT
Credential: MD
Phone: 818-550-0900