Provider Demographics
NPI:1356443808
Name:MARY MARVIN JOHNSON,MD,PA,DBA
Entity Type:Organization
Organization Name:MARY MARVIN JOHNSON,MD,PA,DBA
Other - Org Name:NORTHWEST PEDIATRICS AND ADOLESCENTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.,P.A.,PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-338-8500
Mailing Address - Street 1:4700 SETON CENTER PKWY
Mailing Address - Street 2:#125
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5295
Mailing Address - Country:US
Mailing Address - Phone:512-338-8500
Mailing Address - Fax:512-338-8510
Practice Address - Street 1:4700 SETON CENTER PKWY
Practice Address - Street 2:#125
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5295
Practice Address - Country:US
Practice Address - Phone:512-338-8500
Practice Address - Fax:512-338-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-04
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2730208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty