Active NPI
Johnny Phan
- Other Specialist/Technologist
- San Diego, CA
National Provider Identifier
1114880705
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Other Specialist/Technologist
- License
- 4491866
- Practice address
- 10970 Polaris Dr
San Diego, CA 92126-2459 - Phone
- (858) 775-2261
- NPI assigned
- Dec 9, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Other Specialist/Technologist | 246Z00000X | 4491866 | CA | Primary |
Addresses
Primary practice location
10970 Polaris Dr
San Diego, CA 92126-2459
Mailing address
10970 Polaris Dr
San Diego, CA 92126-2459
Phone (858) 775-2261
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4491866 | CA | MD | Other Specialist/Technologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1765238400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1765238400000",
"number": "1114880705",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10970 POLARIS DR",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921262459",
"telephone_number": "858-775-2261"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10970 POLARIS DR",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921262459",
"telephone_number": "858-775-2261"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHAN",
"first_name": "JOHNNY",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-12-09",
"last_updated": "2025-12-09",
"certification_date": "2025-12-09",
"status": "A"
},
"taxonomies": [
{
"code": "246Z00000X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Other",
"state": "CA",
"license": "4491866",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.