Provider Demographics
NPI:1235115064
Name:JOHNSON, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
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 1:5301 DAVIS LN BLDG B100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4072
Mailing Address - Country:US
Mailing Address - Phone:512-324-2349
Mailing Address - Fax:512-324-2930
Practice Address - Street 1:5301 DAVIS LN BLDG B100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-4072
Practice Address - Country:US
Practice Address - Phone:512-324-2349
Practice Address - Fax:512-324-2930
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0068273208600000X
TXK7172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F6734Medicare PIN