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General NPI Number Information
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NPI Number | 1083696637
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Entity Type | Individual
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Provider Name | JOHNSON BENJAMIN LIGHTFOOTE M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/18/2005
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Last Update Date | 06/11/2011
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Provider Practice Location Address
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Address Line | 1798 N GAREY AVE
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City | POMONA
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State | CA
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Zip | 91767
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Country | US
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Telephone | 909-865-9535
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Fax | 909-630-7394
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Provider Business Mailing Address
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Address Line | 808 S EASTHILLS DR
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City | WEST COVINA
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State | CA
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Zip | 91791-3449
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Country | US
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Telephone | 909-865-9535
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Fax | 909-630-7394
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | G39456
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | G39456
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License Number State | CA
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