Basic Information
| Provider Information | |||||||||
| NPI: | 1295727410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 SETON CENTER PARKWAY | ||||||||
| Address2: | SUITE 215-CREDENTIALING | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787550726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1807 W SLAUGHTER LN STE 490 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787486208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122828967 | ||||||||
| FaxNumber: | 5122925125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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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 | P0909 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 036100533 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 285993602 | 05 | TX | MEDICAID | 36100533 | 05 | IL | MEDICAID | 216741895001 | 01 | ANTHEM | OTHER | 34738800 | 05 | WI | MEDICAID | P00406743 | 01 | MEDICARE RR | OTHER | 285993601 | 05 | TX | MEDICAID |