Basic Information
| Provider Information | |||||||||
| NPI: | 1114927266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 3817 S PADRE ISLAND DR | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784152913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618570178 | ||||||||
| FaxNumber: | 3618554123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J8607 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 136441611 | 05 | TX | MEDICAID | 160908301-1364416-10 | 05 | TX | MEDICAID |