Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 864656 | TX |
NPI | 1114530870 |
---|---|
Provider Name | Thomas Brent Johnson |
First Address | Bandera, TX 78003-4125 |
Second Address | San Antonio, TX 78229-4404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2020 |
Last Update Date | 24/08/2020 |