Basic Information
| Provider Information | |||||||||
| NPI: | 1588634646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1249 AMBLER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796012351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256772626 | ||||||||
| FaxNumber: | 3256776835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1249 AMBLER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796012351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256772626 | ||||||||
| FaxNumber: | 3256776835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | J0025 | TX | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 116139100 | 01 | TN | FIRSTCARE | OTHER | 100007817 | 01 | TX | RAILROAD MEDICARE | OTHER | 125794102 | 05 | TX | MEDICAID | 872921 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |