Provider Demographics
NPI:1063528362
Name:JOHNSON, RICHARD OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:OWEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-924-4000
Mailing Address - Fax:760-924-4091
Practice Address - Street 1:85 SIERRA PARK ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-924-4000
Practice Address - Fax:760-924-4091
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G295401Medicaid
CA00G295401Medicaid