Provider Demographics
NPI:1295727410
Name:JOHNSON, JASON DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:DEAN
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 1:4515 SETON CENTER PARKWAY
Mailing Address - Street 2:SUITE 215-CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1807 W SLAUGHTER LN STE 490
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6208
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-292-5125
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0909207Q00000X
IL036100533207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285993602Medicaid
IL36100533Medicaid
216741895001OtherANTHEM
WI34738800Medicaid
P00406743OtherMEDICARE RR
TX285993601Medicaid
TXTXB139036Medicare PIN
TXTXB139038Medicare PIN
ILK28835Medicare PIN
P00406743OtherMEDICARE RR
216741895001OtherANTHEM
TXP01587750Medicare PIN