Provider Demographics
NPI:1184727562
Name:JOHNSON, PREMILA LAKSHMI SINGH (MD)
Entity type:Individual
Prefix:
First Name:PREMILA
Middle Name:LAKSHMI SINGH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W MICHIGAN AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5808
Mailing Address - Country:US
Mailing Address - Phone:432-683-9898
Mailing Address - Fax:432-695-6102
Practice Address - Street 1:2300 W MICHIGAN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5808
Practice Address - Country:US
Practice Address - Phone:432-683-9898
Practice Address - Fax:432-695-6102
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3739207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094778003Medicaid
TXI73095Medicare UPIN
TX094778003Medicaid