Provider Demographics
NPI:1902867872
Name:JOHNSON, JIMMY DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2301 S HAMPTON RD
Mailing Address - Street 2:STE 900
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224
Mailing Address - Country:US
Mailing Address - Phone:214-330-9201
Mailing Address - Fax:214-339-9577
Practice Address - Street 1:2301 S HAMPTON RD
Practice Address - Street 2:STE 900
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224
Practice Address - Country:US
Practice Address - Phone:214-330-9201
Practice Address - Fax:214-339-9577
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2007-10-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXD0477208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N184Medicare UPIN