Healthcare Provider Details

I. General information

NPI: 1821068347
Provider Name (Legal Business Name): MARY JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
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 Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberG2730
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: