Provider Demographics
NPI:1346244092
Name:JOHNSON, MARVIN WADE SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WADE
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-0478
Mailing Address - Country:US
Mailing Address - Phone:386-496-2406
Mailing Address - Fax:386-496-3362
Practice Address - Street 1:850 E MAIN ST
Practice Address - Street 2:LOT 1
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1348
Practice Address - Country:US
Practice Address - Phone:386-496-2406
Practice Address - Fax:386-496-3362
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0011466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065935500Medicaid
FL53331OtherBCBS
FL53331Medicare PIN
FL065935500Medicaid