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General NPI Number Information
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NPI Number | 1770818734
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Entity Type | Organization
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Legal Business Name | MILLENIUM MEDICAL GROUP
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Dates
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Enumeration Date | 10/08/2009
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Last Update Date | 03/01/2011
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Provider Practice Location Address
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Address Line | 211 S MACLAY AVE
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City | SAN FERNANDO
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State | CA
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Zip | 91340-3603
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Country | US
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Telephone | 818-365-6931
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Fax |
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Provider Business Mailing Address
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Address Line | 2980 N BEVERLY GLEN CIR STE 100
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City | LOS ANGELES
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State | CA
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Zip | 90077-1728
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Country | US
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Telephone | 310-474-9809
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DAVID ROBERT JOHNSON
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Credential | MD
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Telephone | 818-365-6931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A20315
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License Number State | CA
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