Provider Demographics
NPI:1922090497
Name:JOHNSON, JOEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:DAVID
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 1:618 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1665
Mailing Address - Country:US
Mailing Address - Phone:903-596-9900
Mailing Address - Fax:903-596-0242
Practice Address - Street 1:618 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1665
Practice Address - Country:US
Practice Address - Phone:903-596-9900
Practice Address - Fax:903-596-0242
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7829207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079835701Medicaid
TX89660JMedicare ID - Type Unspecified
C17491Medicare UPIN