Provider Demographics
NPI:1093816381
Name:JOHNSON, THERRYLL L (MD)
Entity type:Individual
Prefix:
First Name:THERRYLL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 INDUSTRIAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-868-9300
Mailing Address - Fax:985-851-0053
Practice Address - Street 1:1990 INDUSTRIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-868-9300
Practice Address - Fax:985-873-1766
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1328863Medicaid
LA1328863Medicaid
LAB63596Medicare UPIN
LA52102Medicare PIN