Healthcare Provider Details

I. General information

NPI: 1013163112
Provider Name (Legal Business Name): DIANE L. JOHNSON, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 W 3RD ST
LOS ANGELES CA
90057-1901
US

IV. Provider business mailing address

65 PINE AVE
LONG BEACH CA
90802-4718
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-7111
  • Fax: 213-207-5620
Mailing address:
  • Phone: 714-402-4685
  • Fax: 818-462-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG62317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberG62317
License Number StateCA

VIII. Authorized Official

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