Provider Demographics
NPI:1700812468
Name:JOHNSON & HAVENER MEDICAL SERVICES, PA
Entity Type:Organization
Organization Name:JOHNSON & HAVENER MEDICAL SERVICES, PA
Other - Org Name:FAMILY HEALTH CENTER OF MISSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JERE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-584-3353
Mailing Address - Street 1:1920 E GRIFFIN PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3106
Mailing Address - Country:US
Mailing Address - Phone:956-584-3353
Mailing Address - Fax:956-584-3253
Practice Address - Street 1:1920 E GRIFFIN PKWY
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3106
Practice Address - Country:US
Practice Address - Phone:956-584-3353
Practice Address - Fax:956-584-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CR0547OtherRR MEDICARE
00N26NOtherBLUE CROSS/BLUE SHIELD
CR0547OtherRR MEDICARE