Provider Demographics
NPI:1043491327
Name:BRYAN G. JOHNSON MD, PA
Entity Type:Organization
Organization Name:BRYAN G. JOHNSON MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-633-9300
Mailing Address - Street 1:6842 W MAIN ST
Mailing Address - Street 2:203
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-4243
Mailing Address - Country:US
Mailing Address - Phone:469-633-9300
Mailing Address - Fax:469-633-9301
Practice Address - Street 1:6842 W MAIN ST
Practice Address - Street 2:203
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-4243
Practice Address - Country:US
Practice Address - Phone:469-633-9300
Practice Address - Fax:469-633-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH25302Medicare UPIN