Provider Demographics
NPI:1801893474
Name:JOHNSON, JOE STANLEY (MD)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:STANLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:STAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:220 N RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4148
Mailing Address - Country:US
Mailing Address - Phone:817-556-4800
Mailing Address - Fax:817-556-4825
Practice Address - Street 1:805 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-3816
Practice Address - Country:US
Practice Address - Phone:817-202-3976
Practice Address - Fax:817-202-3978
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126888003Medicaid
TXC17517Medicare UPIN
TX126888003Medicaid