Provider Demographics
NPI:1518192327
Name:JOHNSON, TERRY LYNN (IDMT)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 9 BOX 4704
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09123-0048
Mailing Address - Country:US
Mailing Address - Phone:0049656-593-3666
Mailing Address - Fax:
Practice Address - Street 1:SPANGDAHLEM AB
Practice Address - Street 2:52 MDOS UNIT 3865
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126
Practice Address - Country:US
Practice Address - Phone:0049656-561-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX033936281710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians