Basic Information
| Provider Information | |||||||||
| NPI: | 1003141318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSEN | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
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| 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: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | E4834 | CA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | PO60139080 | WA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | CB220721 | 01 | MEDICARE PTAN | OTHER |