Healthcare Provider Details

I. General information

NPI: 1073557708
Provider Name (Legal Business Name): MARILYN STAROBA JOHNSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CAMINO DE LA SIESTA STE 220
SAN DIEGO CA
92108-3118
US

IV. Provider business mailing address

5030 CAMINO DE LA SIESTA STE 220
SAN DIEGO CA
92108-3118
US

V. Phone/Fax

Practice location:
  • Phone: 619-260-0750
  • Fax: 619-260-0201
Mailing address:
  • Phone: 619-260-0750
  • Fax: 619-260-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT12294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: