Provider Demographics
NPI:1205851672
Name:JOHNSON, FREDERICK C (DO)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7914 ENCLAVE WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-4502
Mailing Address - Country:US
Mailing Address - Phone:214-263-1445
Mailing Address - Fax:
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:SUITE 1610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4474208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S2689OtherBCBS
TX164307406Medicaid
NM23981741Medicaid
TX164307403Medicaid
TX164307404Medicaid
TX1643074Medicare ID - Type Unspecified
TX164307404Medicaid
TX164307406Medicaid
TX265077YKN5Medicare PIN