Basic Information
| Provider Information | |||||||||
| NPI: | 1457521874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 732 LIONEL WAY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761084674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176830354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179271200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 04/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M8741 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | M8741 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.