Healthcare Provider Details

I. General information

NPI: 1093920084
Provider Name (Legal Business Name): XA D. JOHNSON IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W MACARTHUR BLVD DEPARTMENT OF ANESTHESIOLOGY
OAKLAND CA
94611-5641
US

IV. Provider business mailing address

275 W MACARTHUR BLVD DEPARTMENT OF ANESTHESIOLOGY
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-6238
  • Fax:
Mailing address:
  • Phone: 510-752-6238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberA98000
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA98000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: