Provider Demographics
NPI:1306988746
Name:CALIFORNIA OCCUPATIONAL MEDICINE PRACTICE INC
Entity type:Organization
Organization Name:CALIFORNIA OCCUPATIONAL MEDICINE PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:DOUGLASS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-901-6856
Mailing Address - Street 1:PO BOX 52060
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950
Mailing Address - Country:US
Mailing Address - Phone:831-901-6856
Mailing Address - Fax:
Practice Address - Street 1:1142 ROSE AVENUE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662
Practice Address - Country:US
Practice Address - Phone:559-891-8940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA795472083S0010X, 2083X0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty