Provider Demographics
NPI:1730153826
Name:SIERRA NEVADA MEDICAL GROUP
Entity type:Organization
Organization Name:SIERRA NEVADA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-782-8186
Mailing Address - Street 1:1077 FOURTH STREET
Mailing Address - Street 2:SUITE 12
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-543-5640
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1624 LIBRARY LANE
Practice Address - Street 2:SUITE B
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423
Practice Address - Country:US
Practice Address - Phone:775-782-8186
Practice Address - Fax:775-782-4683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty