Healthcare Provider Details

I. General information

NPI: 1790455947
Provider Name (Legal Business Name): SAMUEL TIMOTHY JOHNSON AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2021
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 OLYMPIC BLVD STE 202
WALNUT CREEK CA
94596-5094
US

IV. Provider business mailing address

1900 OLYMPIC BLVD STE 202
WALNUT CREEK CA
94596-5094
US

V. Phone/Fax

Practice location:
  • Phone: 707-494-4328
  • Fax:
Mailing address:
  • Phone: 707-494-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU3617
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberLD61186783
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: