Provider Demographics
NPI:1467633669
Name:FREDRIC D JOHNSON MD PA
Entity Type:Organization
Organization Name:FREDRIC D JOHNSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-346-5266
Mailing Address - Street 1:6100 HARRIS PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4101
Mailing Address - Country:US
Mailing Address - Phone:817-346-5266
Mailing Address - Fax:817-346-5267
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4101
Practice Address - Country:US
Practice Address - Phone:817-346-5266
Practice Address - Fax:817-346-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC17501Medicare UPIN
TX00887TMedicare PIN