Provider Demographics
NPI:1851392401
Name:JOHNSON, FREDRIC DORHAUER (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:DORHAUER
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 1:6100 HARRIS PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4124
Mailing Address - Country:US
Mailing Address - Phone:817-346-5266
Mailing Address - Fax:817-346-5267
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4124
Practice Address - Country:US
Practice Address - Phone:817-346-5266
Practice Address - Fax:817-346-5267
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2007-11-16
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-05-17
Provider Licenses
StateLicense IDTaxonomies
TXG8201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8566B8Medicare PIN
TXC17501Medicare UPIN