Provider Demographics
NPI:1730162892
Name:JOHNSON, MILLARD E (MD)
Entity type:Individual
Prefix:DR
First Name:MILLARD
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-385-5529
Mailing Address - Fax:209-384-3966
Practice Address - Street 1:1510 FLORIDA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4437
Practice Address - Country:US
Practice Address - Phone:209-549-7090
Practice Address - Fax:209-549-7099
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62787208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA061924OtherBOARD CERT #
CA00A627870OtherBLUE SHIELD OF CA PIN
CA00A627870OtherBLUE SHIELD OF CA PIN
CABJ4114106OtherDEA CERT
CAG84816Medicare UPIN