Basic Information
Provider Information | |||||||||
NPI: | 1588727747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | CECILY | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1215 N BISHOP AVE | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752084118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146750906 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3920 W WHEATLAND RD | ||||||||
Address2: | SUITE 108 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752373401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2149487779 | ||||||||
FaxNumber: | 9042443658 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 05/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | TRN10521 | FL | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | N3103 | TX | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.