Provider Demographics
NPI:1275643520
Name:JOHNSON, ALAN J (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:J
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:SCOTT & WHITE MEMORIAL HOSPITAL
Mailing Address - Street 2:2401 S 31ST ST, ENT 4C
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76508-0001
Mailing Address - Country:US
Mailing Address - Phone:254-931-4974
Mailing Address - Fax:254-743-0423
Practice Address - Street 1:SCOTT & WHITE MEMORIAL HOSPITAL
Practice Address - Street 2:2401 S 31ST ST, ENT 4C
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-931-4974
Practice Address - Fax:254-743-0423
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030108207Y00000X
GA30108207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000361303CMedicaid
SCG30108Medicaid
GA04BDBVCMedicare ID - Type UnspecifiedGA MEDICARE
SCG30108Medicaid