Provider Demographics
NPI:1437231677
Name:JOHNSON, REBECCA LOU (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOU
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:FLORIDA GULF COAST UNIVERSITY
Mailing Address - Street 2:10501 FGCU BLVD. SOUTH
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33965-0001
Mailing Address - Country:US
Mailing Address - Phone:239-590-7966
Mailing Address - Fax:
Practice Address - Street 1:FLORIDA GULF COAST UNIVERSITY
Practice Address - Street 2:10501 FGCU BLVD. SOUTH
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33965-0001
Practice Address - Country:US
Practice Address - Phone:239-590-7966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71741207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14162OtherBLUE CROSS OF FLORIDA
FL257876000Medicaid
FL14162OtherBLUE CROSS OF FLORIDA
FL257876000Medicaid
930119096Medicare PIN