Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PP0204X | Pediatric Emergency Physician | 211107 | NY |
N | 207PP0204X | Pediatric Emergency Physician | N4497 | TX |
N | 208000000X | Pediatrician | 211107 | NY |
N | 208000000X | Pediatrician | N4497 | TX |
N | 2080P0203X | Pediatric Critical Care Doctor | 211107 | NY |
Y | 2080P0203X | Pediatric Critical Care Doctor | N4497 | TX |
NPI | 1093886400 |
---|---|
Provider Name | Dr. Bert Emil Johansson |
First Address | El Paso, TX 79905 |
Second Address | El Paso, TX 79905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2006 |
Last Update Date | 04/10/2011 |