Provider Demographics
NPI:1477373967
Name:JOHNSON, BEVERLY LOUISE
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 LEGACY TRCE
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-5688
Mailing Address - Country:US
Mailing Address - Phone:210-887-0416
Mailing Address - Fax:830-947-3763
Practice Address - Street 1:176 LEGACY TRCE
Practice Address - Street 2:
Practice Address - City:LA VERNIA
Practice Address - State:TX
Practice Address - Zip Code:78121-5688
Practice Address - Country:US
Practice Address - Phone:210-887-0416
Practice Address - Fax:830-947-3763
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2024060001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine