=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477682953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRAIG E. JOHNSON MD, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2299 MOWRY AVE SUITE 2A
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-796-3498
-----------------------------------------------------
Fax | 510-794-4109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2299 MOWRY AVE SUITE 2A
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-796-3498
-----------------------------------------------------
Fax | 510-794-4109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CRAIG E JOHNSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 510-796-3498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G86787
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------