Healthcare Provider Details

I. General information

NPI: 1073695557
Provider Name (Legal Business Name): GARY R JOHNSON MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 W ST CHARLES
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

PO BOX 580
SAN ANDREAS CA
95249-0580
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-1851
  • Fax: 209-754-0231
Mailing address:
  • Phone: 209-754-1851
  • Fax: 209-754-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberG27755
License Number StateCA

VIII. Authorized Official

Name: DR. GARY RONALD JOHNSON
Title or Position: OWNER/PHYSICAN
Credential: MD
Phone: 209-754-1851