Provider Demographics
NPI:1386670313
Name:JOHNSON, ANNELLE RAE (MD)
Entity Type:Individual
Prefix:
First Name:ANNELLE
Middle Name:RAE
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 1:350 N CARTWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-7111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 N CARTWRIGHT RD
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495-7111
Practice Address - Country:US
Practice Address - Phone:903-482-9153
Practice Address - Fax:903-482-9514
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017805207QG0300X
TXN8798207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200653200AMedicaid
TX281322202Medicaid
MO1386670313Medicaid
TX281322202Medicaid
MON99000005Medicare PIN
TXTXB125777Medicare PIN