Provider Demographics
NPI:1063515856
Name:JOHNSON, BETHELEN J (MD)
Entity type:Individual
Prefix:DR
First Name:BETHELEN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2020 SUTTER PL
Practice Address - Street 2:#203
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6201
Practice Address - Country:US
Practice Address - Phone:530-750-5880
Practice Address - Fax:530-750-5881
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63157207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A631570Medicaid
00A631571Medicare ID - Type Unspecified
CA00A631572Medicare PIN
CA00A631570Medicaid