Provider Demographics
NPI:1285821413
Name:JOHNSON, LENA E (MD)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LENA
Other - Middle Name:E
Other - Last Name:IRVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2900 VETERANS WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8007
Mailing Address - Country:US
Mailing Address - Phone:321-637-3788
Mailing Address - Fax:321-637-3688
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:321-637-3688
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHL562ZMedicare PIN