Provider Demographics
NPI:1811180318
Name:ROBERT R JOHNSON MEDICAL CORP
Entity type:Organization
Organization Name:ROBERT R JOHNSON MEDICAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-556-2112
Mailing Address - Street 1:3151 AIRWAY AVE
Mailing Address - Street 2:SUITE T2
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:714-556-2112
Mailing Address - Fax:714-556-0120
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:SUITE T2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-556-2112
Practice Address - Fax:714-556-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW12078Medicare PIN