Basic Information
| Provider Information | |||||||||
| NPI: | 1285073890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WALLACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1505 STATE HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757518950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036751725 | ||||||||
| FaxNumber: | 9036754790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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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 | 23591 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 364829701 | 05 | TX | MEDICAID | P01754632 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-2616977-029 | 01 | TX | TRICARE | OTHER | 8GF799 | 01 | TX | BCBS | OTHER |