Provider Demographics
NPI:1053892836
Name:JOHNSON, CLEMENT E JR (MSM)
Entity type:Individual
Prefix:MR
First Name:CLEMENT
Middle Name:E
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 SALK AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-7383
Mailing Address - Country:US
Mailing Address - Phone:855-816-5558
Mailing Address - Fax:855-816-5558
Practice Address - Street 1:2173 SALK AVE STE 250
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7383
Practice Address - Country:US
Practice Address - Phone:855-816-5558
Practice Address - Fax:855-816-5558
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFH102860287171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty