Provider Demographics
NPI:1538109509
Name:JOHNSON, KIMBERLY DIONNE (DO)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:DIONNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:PAVILION II, STE. 640
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-946-4535
Mailing Address - Fax:214-943-8213
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:PAVILION II, STE. 640
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-946-4535
Practice Address - Fax:214-943-8213
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149500405Medicaid
TX149500403Medicaid
TXH54747Medicare UPIN
TX149500405Medicaid
TX8G7293Medicare PIN