Provider Demographics
NPI:1275837205
Name:JOHANNES, JIMMY (MD)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:JOHANNES
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 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3828 SCHAUFELE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1793
Practice Address - Country:US
Practice Address - Phone:657-241-8990
Practice Address - Fax:714-665-4600
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA119213207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine