Provider Demographics
NPI:1184764235
Name:JOHNSON, PAM L (MD)
Entity type:Individual
Prefix:DR
First Name:PAM
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:LASHMET
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1500 UNIVERSITY DR E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2600
Mailing Address - Country:US
Mailing Address - Phone:936-846-1100
Mailing Address - Fax:979-260-9390
Practice Address - Street 1:1905 DOVE CROSSING LN
Practice Address - Street 2:#C
Practice Address - City:NAVASOTA
Practice Address - State:TX
Practice Address - Zip Code:77868-5272
Practice Address - Country:US
Practice Address - Phone:936-825-0000
Practice Address - Fax:936-825-8001
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5254174400000X, 208D00000X, 207VG0400X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-1981OtherPTAN (MEDICARE NUMBER) GRIMES COUNTY COMMUNITY HEALTH CENTER
TX0009516-07OtherTPI (MEDICAID NUMBER) GRIMES COUNTY COMMUNITY HEALTH CENTER
TX74-1715140OtherTIN - BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC.