Provider Demographics
NPI:1104983360
Name:JOHNSON, FREDERICK L (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:L
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 1:987 PARALLEL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5702
Mailing Address - Country:US
Mailing Address - Phone:707-263-7428
Mailing Address - Fax:707-263-7425
Practice Address - Street 1:987 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5702
Practice Address - Country:US
Practice Address - Phone:707-263-7428
Practice Address - Fax:707-263-7425
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA556180207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A556180OtherBLUE SHIELD
CA00A556180Medicaid
CAA55618OtherLICENSE
CN2480OtherRAILROAD MEDICARE
CN2480OtherRAILROAD MEDICARE
CAF53794Medicare UPIN