Provider Demographics
NPI:1326305236
Name:JOHNSON, MATTHEW MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
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 1:2604 ST MICHAEL DR
Mailing Address - Street 2:SUITE 425
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2138
Practice Address - Country:US
Practice Address - Phone:903-885-1740
Practice Address - Fax:903-438-1134
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9391207LP2900X
NJ25MA09855700207L00000X, 207LP2900X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology