Provider Demographics
NPI:1548278534
Name:KARL JOHSENS MD & DRUSILLA LDH LEE MD INC
Entity type:Organization
Organization Name:KARL JOHSENS MD & DRUSILLA LDH LEE MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:KNUDSEN
Authorized Official - Last Name:JOHSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-425-1279
Mailing Address - Street 1:1595 SOQUEL DR STE 340
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1722
Mailing Address - Country:US
Mailing Address - Phone:831-425-1279
Mailing Address - Fax:831-425-3500
Practice Address - Street 1:1595 SOQUEL DR STE 340
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1722
Practice Address - Country:US
Practice Address - Phone:831-425-1279
Practice Address - Fax:831-425-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG084030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G840300OtherBLUE SHIELD
CH1649OtherGROUP MEDICARE RAILROAD
110208332OtherMEDICARE RAILROAD
CA00G840300Medicaid
ZZZ62382ZOtherGROUP BLUE SHIELD CEDAR M
CAG054030OtherBLUE CROSS
610730500OtherUS DEPT OF LABOR OFFICE O
CAGR0090740Medicaid
CAGR0090740Medicaid