Basic Information
| Provider Information | |||||||||
| NPI: | 1205822699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 W TERRELL AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8173368034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 W TERRELL AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8173368034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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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 | 208800000X | E1206 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 124984905 | 05 | TX | MEDICAID | 124984907 | 05 | TX | MEDICAID | 124984908 | 01 | TX | MEDICAID OTHER | OTHER | 124984909 | 05 | TX | MEDICAID | 124984906 | 05 | TX | MEDICAID |