Healthcare Provider Details

I. General information

NPI: 1922428119
Provider Name (Legal Business Name): MICHAEL JOHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2014
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1766
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-5200
  • Fax: 707-573-5417
Mailing address:
  • Phone: 707-573-5200
  • Fax: 707-573-5417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA140871
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1126262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: