Provider Demographics
NPI:1518062207
Name:JOHNSON, FARRELL B (MD)
Entity Type:Individual
Prefix:DR
First Name:FARRELL
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12575 TOULOUSE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-3316
Mailing Address - Country:US
Mailing Address - Phone:713-218-8186
Mailing Address - Fax:713-218-8186
Practice Address - Street 1:12575 TOULOUSE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3316
Practice Address - Country:US
Practice Address - Phone:713-218-8186
Practice Address - Fax:713-218-8186
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4009302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1577294Medicaid
LA4E829Medicare ID - Type Unspecified
LA1577294Medicaid