Provider Demographics
NPI:1093864423
Name:JOHNSON, JAMES ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 CAMINO DE LOS MARES 200
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2838
Mailing Address - Country:US
Mailing Address - Phone:949-429-6000
Mailing Address - Fax:949-429-6001
Practice Address - Street 1:901 CALLE AMANECER
Practice Address - Street 2:STE 100
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6278
Practice Address - Country:US
Practice Address - Phone:949-218-1482
Practice Address - Fax:949-218-1470
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080183937OtherRAILROAD MEDICARE
CA5422000G694270OtherBLUE SHIELD
260042944926730000OtherTRICARE
CA260042944OtherBLUE CROSS
CA5422000G694270OtherBLUE SHIELD
F22693Medicare UPIN