Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 1273 | TX |
N | 222Z00000X | Podiatrist | 1273 | TX |
Y | 224P00000X | Prosthetist | 1273 | TX |
NPI | 1366673303 |
---|---|
Provider Name | Jon Robert Johnson |
First Address | Fort Worth, TX 76110-1349 |
Second Address | Ft Worth, TX 76110-1349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2009 |
Last Update Date | 21/06/2013 |