Provider Demographics
NPI:1447221031
Name:JOHNSON, JEREMY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PINE CT
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9131
Mailing Address - Country:US
Mailing Address - Phone:808-895-9420
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN
Practice Address - Street 2:
Practice Address - City:LOCKNEY
Practice Address - State:TX
Practice Address - Zip Code:79241
Practice Address - Country:US
Practice Address - Phone:806-652-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6394207P00000X
NMA-2434-20207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine