Provider Demographics
NPI:1063462331
Name:JOHNSON, WELDON R JR (DO)
Entity type:Individual
Prefix:DR
First Name:WELDON
Middle Name:R
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4356
Mailing Address - Country:US
Mailing Address - Phone:972-475-1351
Mailing Address - Fax:972-412-8220
Practice Address - Street 1:7617 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4356
Practice Address - Country:US
Practice Address - Phone:972-475-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339259YKQLMedicare PIN
TXA67201Medicare UPIN
TX00QM21Medicare PIN
TX339259YKP5Medicare PIN