=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245457407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURANCE FOLKEY JOHNSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 E. DEL MAR BIVD. SUITE 7
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-793-5480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 MONTEREY RD
-----------------------------------------------------
City | SAN MARINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91108-1645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-441-5521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | G017122
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------