Provider Demographics
NPI:1295821577
Name:JOHNSON, RANDALL WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WILLIAM
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 1:9201 PINECROFT DR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3222
Mailing Address - Country:US
Mailing Address - Phone:281-297-6476
Mailing Address - Fax:
Practice Address - Street 1:9201 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3222
Practice Address - Country:US
Practice Address - Phone:281-297-6476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4719207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149140901Medicaid
TXH37690Medicare UPIN
GA660003697Medicare PIN
TX149140901Medicaid