Provider Demographics
NPI:1144399676
Name:JOHNSON, JAMES H (MD PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-9738
Mailing Address - Country:US
Mailing Address - Phone:863-965-1746
Mailing Address - Fax:863-683-9805
Practice Address - Street 1:2112 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2906
Practice Address - Country:US
Practice Address - Phone:863-688-0540
Practice Address - Fax:863-683-9805
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0008984174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064925200Medicaid
FL064925200Medicaid
FLD70628Medicare UPIN