Provider Demographics
NPI:1639207467
Name:JOHNSON, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S BROOKSIDE DR APT 2207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4585
Mailing Address - Country:US
Mailing Address - Phone:214-557-0624
Mailing Address - Fax:
Practice Address - Street 1:12250 INWOOD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-8033
Practice Address - Country:US
Practice Address - Phone:972-701-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist