Basic Information
| Provider Information | |||||||||
| NPI: | 1417191990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIANE L. JOHNSON M.D. INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 PINE AVE | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144024685 | ||||||||
| FaxNumber: | 5628560389 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 PINE AVE | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144024685 | ||||||||
| FaxNumber: | 5628560389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7144024685 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | G62317 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | G62317 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | G62317 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013962273 | 01 | CA | INDIV . NPI | OTHER |