Provider Demographics
NPI:1346320603
Name:JOHNSON, YVETTE R (MD)
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:817-347-9601
Practice Address - Fax:817-347-9602
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM18042080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175718901Medicaid
TXTXB118037Medicare PIN
8D8609Medicare ID - Type Unspecified
TX175718901Medicaid