Healthcare Provider Details

I. General information

NPI: 1962693655
Provider Name (Legal Business Name): JONATHAN TODD JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N GREENVILLE AVE STE 110
ALLEN TX
75002-8861
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-303-2600
  • Fax: 682-303-2601
Mailing address:
  • Phone: 682-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN6895
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: