Healthcare Provider Details

I. General information

NPI: 1780277194
Provider Name (Legal Business Name): AVERY WILLIAM JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 STURGIS RD
TWENTYNINE PALMS CA
92278
US

IV. Provider business mailing address

1145 STURGIS RD
TWENTYNINE PALMS CA
92278
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2190
  • Fax:
Mailing address:
  • Phone: 760-830-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101275950
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: