Provider Demographics
NPI:1598754194
Name:JOHNSON, SHAWN R (MD)
Entity Type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
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 841526
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-0075
Mailing Address - Country:US
Mailing Address - Phone:713-436-7023
Mailing Address - Fax:713-340-0481
Practice Address - Street 1:2734 SUNRISE BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8514
Practice Address - Country:US
Practice Address - Phone:713-436-4007
Practice Address - Fax:713-340-0481
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17735207Q00000X
TXK8919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0051TLOtherBCBS
TX8F5948Medicare PIN
MSH44477Medicare UPIN
MS080003739Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER