Healthcare Provider Details

I. General information

NPI: 1063528362
Provider Name (Legal Business Name): RICHARD OWEN JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SIERRA PARK ROAD SUITE A
MAMMOTH LAKES CA
93546
US

IV. Provider business mailing address

PO BOX 660
MAMMOTH LAKES CA
93546-0660
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-4000
  • Fax: 760-924-4091
Mailing address:
  • Phone: 760-924-4000
  • Fax: 760-924-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG29540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: