Provider Demographics
NPI:1992827802
Name:JOHNSON, GARY ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 BRIARCREST DR
Mailing Address - Street 2:STE 800
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2763
Mailing Address - Country:US
Mailing Address - Phone:979-846-2878
Mailing Address - Fax:979-846-2877
Practice Address - Street 1:1716 BRIARCREST DR
Practice Address - Street 2:STE 800
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2763
Practice Address - Country:US
Practice Address - Phone:979-846-2878
Practice Address - Fax:979-846-2877
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1107241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T1220OtherFEDERAL BCBS P.T.
TX0041JZOtherBCBS OUTPATIENT P.T.
TX1639130-01Medicaid
TX1639130-01Medicaid