Provider Demographics
NPI:1780919282
Name:JOHNSON, WALTER KIP (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:KIP
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:W.
Other - Middle Name:KIP
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:209-754-6275
Practice Address - Street 1:305 PRESTON AVE
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-9158
Practice Address - Country:US
Practice Address - Phone:209-742-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32232208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice