Healthcare Provider Details

I. General information

NPI: 1053391243
Provider Name (Legal Business Name): MICHAEL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4663 SCOTTS VALLEY DR
SCOTTS VALLEY CA
95066-4202
US

IV. Provider business mailing address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-6330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG50420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: