Healthcare Provider Details

I. General information

NPI: 1568903888
Provider Name (Legal Business Name): MAXWELL BATES JOHNSON MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SAN PABLO ST STE 415
LOS ANGELES CA
90033-5403
US

IV. Provider business mailing address

867 MONTEREY RD
SOUTH PASADENA CA
91030-3157
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-7903
  • Fax:
Mailing address:
  • Phone: 323-202-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA159221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: