Healthcare Provider Details

I. General information

NPI: 1174579593
Provider Name (Legal Business Name): JOHN GORDON JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 ROUND ROCK AVE
ROUND ROCK TX
78681-4004
US

IV. Provider business mailing address

505 SHERWOOD CT
GEORGETOWN TX
78628-4678
US

V. Phone/Fax

Practice location:
  • Phone: 512-341-1000
  • Fax:
Mailing address:
  • Phone: 512-864-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberM0769
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: