Provider Demographics
NPI:1629179494
Name:JOHNSON, GREGORY R (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
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 1:1301 S COULTER ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1763
Mailing Address - Country:US
Mailing Address - Phone:806-358-9111
Mailing Address - Fax:806-358-3728
Practice Address - Street 1:1301 S COULTER ST
Practice Address - Street 2:SUITE 405
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1763
Practice Address - Country:US
Practice Address - Phone:806-358-9111
Practice Address - Fax:806-358-3728
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157811401Medicaid
TXH80125Medicare UPIN
TX157811401Medicaid