Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0129X | Vascular Surgeon | E8004 | TX |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | E8004 | TX |
NPI | 1124027164 |
---|---|
Provider Name | George William Johnson JR. |
First Address | Denton, TX 76210-6817 |
Second Address | Denton, TX 76210-6817 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 11/07/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
098128403 | (05) | TX |
E66765 | (02) |