Provider Demographics
NPI:1386852051
Name:JOHNSON, NICHOLE KAY (MD)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:KAY
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 1:4001 W 15TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5841
Mailing Address - Country:US
Mailing Address - Phone:214-463-7671
Mailing Address - Fax:214-473-7680
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:STE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:214-463-7671
Practice Address - Fax:214-473-7680
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6638207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199018601Medicaid
TX8G0899OtherBCBS
TX199018602Medicaid
TX8CZ856OtherBCBSTX
TXTXB132520Medicare PIN
TX199018601Medicaid
TX8K6078Medicare PIN