Healthcare Provider Details

I. General information

NPI: 1013199124
Provider Name (Legal Business Name): MATTHEW DAVID JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 THE CITY DRIVE DEPT. OF PHYSICAL MEDICINE, B13
ORANGE CA
92868
US

IV. Provider business mailing address

1, THE CITY DRIVE DEPT. OF PHYSICAL MEDICINE, B13
ORANGE CA
92868
US

V. Phone/Fax

Practice location:
  • Phone: 877-824-3627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20A 10073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: