Healthcare Provider Details

I. General information

NPI: 1487220968
Provider Name (Legal Business Name): BLAKE ALAN JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

V. Phone/Fax

Practice location:
  • Phone: 409-747-5727
  • Fax: 409-747-5715
Mailing address:
  • Phone: 409-747-5727
  • Fax: 409-747-5715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberBP10074436
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: