Provider Demographics
NPI:1003931882
Name:JOHNSON, CLINTON
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 FOREST VALE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-7215
Mailing Address - Country:US
Mailing Address - Phone:210-568-9307
Mailing Address - Fax:
Practice Address - Street 1:7610 FOREST VALE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-7215
Practice Address - Country:US
Practice Address - Phone:210-568-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator