Provider Demographics
NPI:1841961034
Name:JOHNSON, GREGORY CALVIN (IDHS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:CALVIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W MAPLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:PORT O CONNOR
Mailing Address - State:TX
Mailing Address - Zip Code:77982-2205
Mailing Address - Country:US
Mailing Address - Phone:361-983-2617
Mailing Address - Fax:
Practice Address - Street 1:2307 W MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:PORT O CONNOR
Practice Address - State:TX
Practice Address - Zip Code:77982-2205
Practice Address - Country:US
Practice Address - Phone:361-983-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman