Provider Demographics
NPI:1518937705
Name:JOHNSON, ERIC R (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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 1:2801 OSLER DR
Mailing Address - Street 2:#120
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051
Mailing Address - Country:US
Mailing Address - Phone:972-647-8404
Mailing Address - Fax:972-641-8398
Practice Address - Street 1:2801 OSLER DR
Practice Address - Street 2:#120
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051
Practice Address - Country:US
Practice Address - Phone:972-647-8404
Practice Address - Fax:972-641-8398
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6441207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126321203Medicaid
00DE90Medicare ID - Type Unspecified
TX126321203Medicaid