Healthcare Provider Details

I. General information

NPI: 1356443808
Provider Name (Legal Business Name): MARY MARVIN JOHNSON,MD,PA,DBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SETON CENTER PKWY #125
AUSTIN TX
78759-5295
US

IV. Provider business mailing address

4700 SETON CENTER PKWY #125
AUSTIN TX
78759-5295
US

V. Phone/Fax

Practice location:
  • Phone: 512-338-8500
  • Fax: 512-338-8510
Mailing address:
  • Phone: 512-338-8500
  • Fax: 512-338-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG2730
License Number StateTX

VIII. Authorized Official

Name: DR. MARY JOHNSON
Title or Position: M.D.,P.A.,PRESIDENT
Credential: M.D.
Phone: 512-338-8500