Provider Demographics
NPI:1699017871
Name:JOHNSON, DEIDRA (RD, CDE)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 SWISS AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6251
Mailing Address - Country:US
Mailing Address - Phone:214-828-5010
Mailing Address - Fax:214-828-5011
Practice Address - Street 1:3434 SWISS AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6251
Practice Address - Country:US
Practice Address - Phone:214-828-5010
Practice Address - Fax:214-828-5011
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283916YNQJMedicare PIN