Provider Demographics
NPI:1689609125
Name:JOHNSON, DAVID GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GARY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:G
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:311 W ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2219
Mailing Address - Country:US
Mailing Address - Phone:210-394-0389
Mailing Address - Fax:830-535-6423
Practice Address - Street 1:311 W ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2219
Practice Address - Country:US
Practice Address - Phone:210-394-0389
Practice Address - Fax:830-535-6423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF52432084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D729OtherBLUECROSS BLUESHIELD
TXC17524Medicare UPIN
TX00D729Medicare ID - Type Unspecified