Provider Demographics
NPI:1376747196
Name:J. DAVID JOHNSON,MD,PA
Entity Type:Organization
Organization Name:J. DAVID JOHNSON,MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFC MGR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:903-596-9900
Mailing Address - Street 1:618 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1665
Mailing Address - Country:US
Mailing Address - Phone:903-596-9900
Mailing Address - Fax:903-596-0242
Practice Address - Street 1:618 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1665
Practice Address - Country:US
Practice Address - Phone:903-596-9900
Practice Address - Fax:903-596-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7829174400000X
TXK4497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128264203Medicaid
TX89660JMedicare PIN
TXC17491Medicare UPIN