MEDICARE: CALIFORNIA EYE AND FACIAL PLASTIC SURGERY

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	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	042000760	OTHER	IL	DEPARTMENT OF FINANCIAL AND PROFRESSIONAL REGULATION

General Provider Information

NPI Number	:	1538399761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA EYE AND FACIAL PLASTIC SURGERY

Provider Business Mailing Address
First Line	:	1812 PORT ABBEY PL
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5310
Country	:	US
Telephone Number	:	801-699-5945
Fax Number	:

Provider Business Practice Location Address
First Line	:	1812 PORT ABBEY PL
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5310
Country	:	US
Telephone Number	:	801-699-5945
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN JOHNSEN
Credential	:	MD
Telephone Number	:	801-699-5945

Provider Enumeration Date	:	07/22/2009
Last Update Date	:	01/17/2019

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