Provider Demographics
NPI:1386696136
Name:DELLOSA, JOHNSON DIAZ (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:DIAZ
Last Name:DELLOSA
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:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-0278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 EAST HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:ALVARADO
Practice Address - State:TX
Practice Address - Zip Code:76009
Practice Address - Country:US
Practice Address - Phone:817-783-2318
Practice Address - Fax:817-783-2319
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AS312OtherBCBS
TX1386696136Medicaid