Provider Demographics
NPI:1962863217
Name:JOHNSON, CARLDALE
Entity Type:Individual
Prefix:
First Name:CARLDALE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY BLVD
Mailing Address - Street 2:APT. 224
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-8005
Mailing Address - Country:US
Mailing Address - Phone:512-659-1519
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY BLVD
Practice Address - Street 2:APT. 224
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8005
Practice Address - Country:US
Practice Address - Phone:512-659-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21265190343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)