Basic Information
Provider Information | |||||||||
NPI: | 1073654000 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HELEN V & FRED JOHNSON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKE COUNTY ANESTHESIA MEDICAL ASSO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 951 | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 912090951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185500900 | ||||||||
FaxNumber: | 8185500909 | ||||||||
Practice Location | |||||||||
Address1: | 5176 HILL RD E | ||||||||
Address2: |   | ||||||||
City: | LAKEPORT | ||||||||
State: | CA | ||||||||
PostalCode: | 954536300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072625000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2007 | ||||||||
LastUpdateDate: | 06/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | FREDERICK | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8185500900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ60330Z | 01 | CA | BLUE SHIELD | OTHER | GR0071440 | 05 | CA |   | MEDICAID |