Provider Demographics
NPI:1942390430
Name:JOHNSON, DALLAS (MD)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:
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 1:4600 GULF FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77023
Mailing Address - Country:US
Mailing Address - Phone:713-522-6240
Mailing Address - Fax:
Practice Address - Street 1:12614 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3839
Practice Address - Country:US
Practice Address - Phone:713-514-1100
Practice Address - Fax:404-494-7435
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4925207V00000X
TXH4441207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163442001Medicaid
5N674Medicare PIN