Basic Information
| Provider Information | |||||||||
| NPI: | 1255347340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RALEIGH | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3560 DELAWARE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777063059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098993682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3560 DELAWARE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777063059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098993682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/30/2010 | ||||||||
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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 | 2085R0202X | 2002010815 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | L1084 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 149233001 | 05 | AR | MEDICAID | 185214 | 01 | MO | MO BLUE CROSS BLUE SHIELD | OTHER | 524893 | 01 | HEALTHLINK | OTHER | 205919806 | 05 | MO | MEDICAID | BJ7071753 | 01 | DEA | OTHER | L1084 | 01 | TX | MEDICAL LICENSE | OTHER | 430954380CAP | 01 | MERCY HEALTH PLAN | OTHER | 036-107490 | 01 | IL | IL BLUE CROSS BLUE SHIELD | OTHER | 063896 | 01 | HEALTH ALLIANCE | OTHER | 60117868 | 01 | TX | DPS | OTHER |