Provider Demographics
NPI:1205822699
Name:JOHNSON, JAMES DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DANIEL
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 1:1300 W TERRELL AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-784-8268
Mailing Address - Fax:817-336-8034
Practice Address - Street 1:1300 W TERRELL AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-336-8034
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1206208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124984905Medicaid
TX124984907Medicaid
TX124984908OtherMEDICAID OTHER
TX124984909Medicaid
TX124984906Medicaid
TX124984909Medicaid
TX124984906Medicaid
TX124984907Medicaid