Provider Demographics
NPI:1164422077
Name:JOHNSON, RICHARD FREDERCIK (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FREDERCIK
Last Name:JOHNSON
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 1:1400 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1013
Mailing Address - Country:US
Mailing Address - Phone:727-586-0047
Mailing Address - Fax:727-585-7867
Practice Address - Street 1:1400 E BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-1013
Practice Address - Country:US
Practice Address - Phone:727-586-0047
Practice Address - Fax:727-585-7867
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME253962083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1708085OtherWORK COMP CERTIFICATION #
FL52871Medicare ID - Type Unspecified
FLA34955Medicare UPIN