Provider Demographics
NPI:1376568485
Name:JOHNSON, RAYMOND R (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:R
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 1:11661 PRESTON RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2745
Mailing Address - Country:US
Mailing Address - Phone:214-363-4031
Mailing Address - Fax:214-363-7243
Practice Address - Street 1:11661 PRESTON RD
Practice Address - Street 2:SUITE 120
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2745
Practice Address - Country:US
Practice Address - Phone:214-363-4031
Practice Address - Fax:214-363-7243
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7019208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126982103Medicaid
TX87W823Medicare ID - Type Unspecified
TXB53902Medicare UPIN