Provider Demographics
NPI:1528081775
Name:JOHANSON, NOEL E (MD)
Entity type:Individual
Prefix:MR
First Name:NOEL
Middle Name:E
Last Name:JOHANSON
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 1:500 S ANAHEIM HILLS RD
Mailing Address - Street 2:# 200
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4780
Mailing Address - Country:US
Mailing Address - Phone:714-809-6289
Mailing Address - Fax:
Practice Address - Street 1:500 S ANAHEIM HILLS RD
Practice Address - Street 2:# 200
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4780
Practice Address - Country:US
Practice Address - Phone:714-809-6289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17121207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G171210Medicaid
A39993Medicare UPIN
CAG17121Medicare ID - Type Unspecified