Provider Demographics
NPI:1447403274
Name:JOHNSON, EUGENE (IDC)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:EUGENE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IDC
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:NAVAL AIR STATION
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:904-542-3500
Mailing Address - Fax:904-542-4125
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:NAVAL AIR STATION
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-3500
Practice Address - Fax:904-542-4125
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman