Provider Demographics
NPI:1689675142
Name:JOHNSON, ROBERT GORDON (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GORDON
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 1:4410 MEDICAL DR
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6306
Mailing Address - Country:US
Mailing Address - Phone:210-614-2453
Mailing Address - Fax:210-614-4457
Practice Address - Street 1:4410 MEDICAL DR
Practice Address - Street 2:SUITE 610
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6306
Practice Address - Country:US
Practice Address - Phone:210-614-2453
Practice Address - Fax:210-614-4457
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7249207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133865903Medicaid
00K501Medicare ID - Type Unspecified
TX133865903Medicaid