Provider Demographics
NPI:1699866079
Name:JOHNSON, SANDRA C (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:#10
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-758-1122
Practice Address - Fax:530-758-1646
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G588300Medicare ID - Type Unspecified
A53449Medicare UPIN