Provider Demographics
NPI:1053309252
Name:JOHNSON, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 OCEAN DR.
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1343
Mailing Address - Country:US
Mailing Address - Phone:361-549-1758
Mailing Address - Fax:281-784-1555
Practice Address - Street 1:3614 OCEAN DR.
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1343
Practice Address - Country:US
Practice Address - Phone:361-549-1758
Practice Address - Fax:281-784-1555
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3186207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P5507OtherBCBS PROVIDER NUMBER
TX1053309252OtherTRICARE SOUTH
TX140034325Medicaid
TX8P5507OtherBCBS PROVIDER NUMBER
TXP00192822Medicare PIN
TXC17523Medicare UPIN