Healthcare Provider Details

I. General information

NPI: 1457300477
Provider Name (Legal Business Name): JACOB JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST RM 933 STE 933
SAN FRANCISCO CA
94108-3997
US

IV. Provider business mailing address

450 SUTTER ST RM 933 STE 933
SAN FRANCISCO CA
94108-3997
US

V. Phone/Fax

Practice location:
  • Phone: 415-362-5443
  • Fax: 415-362-2429
Mailing address:
  • Phone: 415-362-5443
  • Fax: 415-362-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA065871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: