Healthcare Provider Details

I. General information

NPI: 1841961034
Provider Name (Legal Business Name): GREGORY CALVIN JOHNSON IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 W MAPLE ST STE B
PORT O CONNOR TX
77982-2205
US

IV. Provider business mailing address

2307 W MAPLE ST STE B
PORT O CONNOR TX
77982-2205
US

V. Phone/Fax

Practice location:
  • Phone: 361-983-2617
  • Fax:
Mailing address:
  • Phone: 361-983-2617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: