Provider Demographics
NPI:1700170255
Name:JOHANSEN, BENJAMIN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NASA PARKWAY
Mailing Address - Street 2:SD3
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058
Mailing Address - Country:US
Mailing Address - Phone:832-205-5371
Mailing Address - Fax:
Practice Address - Street 1:2101 NASA PARKWAY
Practice Address - Street 2:SD3
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058
Practice Address - Country:US
Practice Address - Phone:832-205-5371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ11802083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine