Provider Demographics
NPI:1609927342
Name:JOHNSON, SHAWN EVETTE (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:EVETTE
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 1:235 W PALM ST STE 108
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-1300
Mailing Address - Country:US
Mailing Address - Phone:979-413-4340
Mailing Address - Fax:979-413-7349
Practice Address - Street 1:235 W PALM ST STE 108
Practice Address - Street 2:
Practice Address - City:BELLVILLE
Practice Address - State:TX
Practice Address - Zip Code:77418-1300
Practice Address - Country:US
Practice Address - Phone:979-413-4840
Practice Address - Fax:979-413-7349
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3902207X00000X, 207XX0005X
NE23310207X00000X
VA0101252896207X00000X
LAMD.205784207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2334361Medicaid
MS05024837Medicaid
TX3925117Medicaid
VA1609927342Medicaid
LA369912YH3UMedicare PIN