Healthcare Provider Details

I. General information

NPI: 1548278534
Provider Name (Legal Business Name): KARL JOHSENS MD & DRUSILLA LDH LEE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 SOQUEL DR STE 340
SANTA CRUZ CA
95065-1722
US

IV. Provider business mailing address

1595 SOQUEL DR STE 340
SANTA CRUZ CA
95065-1722
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-1279
  • Fax: 831-425-3500
Mailing address:
  • Phone: 831-425-1279
  • Fax: 831-425-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG084030
License Number StateCA

VIII. Authorized Official

Name: DR. KARL KNUDSEN JOHSEN
Title or Position: PHYSICIAN PRESIDENT
Credential: MD
Phone: 831-425-1279