Provider Demographics
NPI:1629020235
Name:JOHANNSEN, LEE (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:JOHANNSEN
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 1:2309 BERRY HILL CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3506
Mailing Address - Country:US
Mailing Address - Phone:512-804-0221
Mailing Address - Fax:
Practice Address - Street 1:901 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6903
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4922207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104601302Medicaid
TX104601303Medicaid
TX8971J2Medicare ID - Type Unspecified
TX104601303Medicaid
TXF70361Medicare UPIN