Basic Information
Provider Information
NPI: 1003141318
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSEN
FirstName: CLAYTON
MiddleName: GARY
NamePrefix: DR.
NameSuffix:  
Credential: D.P.M.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1762 N WATERMAN AVE
Address2:  
City: SAN BERNARDINO
State: CA
PostalCode: 924045130
CountryCode: US
TelephoneNumber: 9098863668
FaxNumber: 9098865542
Practice Location
Address1: 1762 N WATERMAN AVE
Address2:  
City: SAN BERNARDINO
State: CA
PostalCode: 924045130
CountryCode: US
TelephoneNumber: 9098863668
FaxNumber: 9098865542
Other Information
ProviderEnumerationDate: 10/05/2009
LastUpdateDate: 05/11/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213E00000XE4834CAN Podiatric Medicine & Surgery Service ProvidersPodiatrist 
213ES0103XPO60139080WAY Podiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery

ID Information
IDTypeStateIssuerDescription
CB22072101 MEDICARE PTANOTHER


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