Provider Demographics
NPI:1477576965
Name:HARTONO, JOHN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HARTONO
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 1:4708 ALLIANCE BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5340
Mailing Address - Country:US
Mailing Address - Phone:469-467-0011
Mailing Address - Fax:
Practice Address - Street 1:7150 N PRESIDENT GEORGE BUSH HWY STE 205
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-2210
Practice Address - Country:US
Practice Address - Phone:972-276-0139
Practice Address - Fax:972-276-0149
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0223207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285504101Medicaid
TX285504102Medicaid
TX285504101Medicaid
TX285504102Medicaid