Healthcare Provider Details

I. General information

NPI: 1902647290
Provider Name (Legal Business Name): MADYSEN JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 RED RIVER ST
AUSTIN TX
78712-1845
US

IV. Provider business mailing address

1500 RED RIVER ST
AUSTIN TX
78701-1918
US

V. Phone/Fax

Practice location:
  • Phone: 512-657-7228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10089715
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: