Healthcare Provider Details

I. General information

NPI: 1881129419
Provider Name (Legal Business Name): JACK ALSTON JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 LONE STAR RD
MANSFIELD TX
76063-8744
US

IV. Provider business mailing address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

V. Phone/Fax

Practice location:
  • Phone: 877-847-9355
  • Fax:
Mailing address:
  • Phone: 817-496-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR9985
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: