MEDICARE: BERT JAY JOHNS III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	G62546	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053395848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERT JAY JOHNS III MD

Provider Business Mailing Address
First Line	:	1800 SULLIVAN AVE
Second Line	:	SUITE 507
City	:	DALY CITY
State	:	CA
Zip	:	94015-2225
Country	:	US
Telephone Number	:	650-994-9936
Fax Number	:	650-994-2016

Provider Business Practice Location Address
First Line	:	1800 SULLIVAN AVE
Second Line	:	SUITE 507
City	:	DALY CITY
State	:	CA
Zip	:	94015-2225
Country	:	US
Telephone Number	:	650-994-9936
Fax Number	:	650-994-2016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	04/29/2009

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