Basic Information
| Provider Information | |||||||||
| NPI: | 1144203258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TOBY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATT CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 E HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592565200 | ||||||||
| FaxNumber: | 5592565376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | A87693 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 12294965-1205 | UT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0196688 | 01 | CA | STATE OF WASHINGTON | OTHER | P00276609 | 01 | CA | RAILROAD MEDICARE | OTHER |