Provider Demographics
NPI:1861582561
Name:JOHNSON, TERRY L (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 BUCHANAN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1856
Mailing Address - Country:US
Mailing Address - Phone:940-696-1600
Mailing Address - Fax:940-696-1665
Practice Address - Street 1:3506 BUCHANAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1856
Practice Address - Country:US
Practice Address - Phone:940-696-1600
Practice Address - Fax:940-696-1665
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5795208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205122-05Medicaid
TX1205122-05Medicaid