Provider Demographics
NPI:1871787614
Name:JOHNSON, RAYMOND LOUIS (IDC)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:LOUIS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 CORAL SEA RD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-5055
Mailing Address - Country:US
Mailing Address - Phone:361-776-1374
Mailing Address - Fax:361-776-1103
Practice Address - Street 1:327 CORAL SEA RD
Practice Address - Street 2:SUITE 165
Practice Address - City:INGLESIDE
Practice Address - State:TX
Practice Address - Zip Code:78362-5055
Practice Address - Country:US
Practice Address - Phone:361-776-1374
Practice Address - Fax:361-776-1103
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman