Healthcare Provider Details

I. General information

NPI: 1417191990
Provider Name (Legal Business Name): DIANE L. JOHNSON M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 PINE AVE SUITE 19
LONG BEACH CA
90802-4718
US

IV. Provider business mailing address

65 PINE AVE SUITE 19
LONG BEACH CA
90802-4718
US

V. Phone/Fax

Practice location:
  • Phone: 714-402-4685
  • Fax: 562-856-0389
Mailing address:
  • Phone: 714-402-4685
  • Fax: 562-856-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG62317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG62317
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG62317
License Number StateCA

VIII. Authorized Official

Name: DR. DIANE L. JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-402-4685