Provider Demographics
NPI:1578506903
Name:JOHNSON, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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:PO BOX 840020
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0020
Mailing Address - Country:US
Mailing Address - Phone:806-358-0200
Mailing Address - Fax:806-356-5590
Practice Address - Street 1:6700 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1729
Practice Address - Country:US
Practice Address - Phone:806-358-0200
Practice Address - Fax:806-356-5511
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8596207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124113505Medicaid
TX348032ZGE1Medicare UPIN
TXC17509Medicare UPIN