Provider Demographics
NPI:1093886400
Name:JOHANSSON, BERT EMIL (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:EMIL
Last Name:JOHANSSON
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 ALBERTA DR
Mailing Address - Street 2:DEPT PEDIATRICS; TEXAS TECH HEALTH SCIENCES CTR
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905
Mailing Address - Country:US
Mailing Address - Phone:915-545-6921
Mailing Address - Fax:915-545-6975
Practice Address - Street 1:4800 ALBERTA DR
Practice Address - Street 2:DEPT PEDIATRICS; TEXAS TECH HEALTH SCIENCES CTR
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-6921
Practice Address - Fax:915-545-6975
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211107207PP0204X, 208000000X, 2080P0203X
TXN44972080P0203X, 208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics