Provider Demographics
NPI:1417675182
Name:JOHNSON, GBENGA PETER
Entity Type:Individual
Prefix:
First Name:GBENGA
Middle Name:PETER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13811 ROMAN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-1247
Mailing Address - Country:US
Mailing Address - Phone:832-488-9109
Mailing Address - Fax:
Practice Address - Street 1:13811 ROMAN RIDGE LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-1247
Practice Address - Country:US
Practice Address - Phone:832-488-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44582585171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications