Basic Information
| Provider Information | |||||||||
| NPI: | 1487679684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 959 | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934650959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054341375 | ||||||||
| FaxNumber: | 8054341716 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 LAS PRADERAS DR | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055447832 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | A33572 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00A335721 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | 00A335720 | 05 | CA | MEDICAID |