Provider Demographics
NPI:1356351977
Name:JOHNSON, NATALIE INGE (MD)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:INGE
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 1:1000 E. 5TH STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-596-3500
Mailing Address - Fax:903-596-3553
Practice Address - Street 1:1000 E 5TH ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3346
Practice Address - Country:US
Practice Address - Phone:903-596-3500
Practice Address - Fax:903-596-3553
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36510207R00000X
TXQ1633207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4091459OtherBLUE CROSS PROVIDER #
TN4091459OtherBLUE CROSS PROVIDER #
TNH63048Medicare UPIN