Provider Demographics
NPI:1023281177
Name:KIMBERLY D JOHNSON, DO, PA
Entity type:Organization
Organization Name:KIMBERLY D JOHNSON, DO, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-948-3518
Mailing Address - Street 1:1411 N BECKLEY AVE
Mailing Address - Street 2:PAVILION III, STE. 352
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1259
Mailing Address - Country:US
Mailing Address - Phone:214-943-2249
Mailing Address - Fax:214-943-8213
Practice Address - Street 1:1411 N BECKLEY AVE
Practice Address - Street 2:PAVILION III, STE. 352
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1259
Practice Address - Country:US
Practice Address - Phone:214-943-2249
Practice Address - Fax:214-943-8213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179397801Medicaid
TX179397801Medicaid
TXTXB136171Medicare PIN