Provider Demographics
NPI:1477590248
Name:JOHNSON, RICHARD W (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SOUTHPARK BLVD
Mailing Address - Street 2:STE 208
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3129
Mailing Address - Country:US
Mailing Address - Phone:904-826-1900
Mailing Address - Fax:904-826-1920
Practice Address - Street 1:200 SOUTHPARK BLVD
Practice Address - Street 2:STE 208
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3129
Practice Address - Country:US
Practice Address - Phone:904-826-1900
Practice Address - Fax:904-826-1920
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2829213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340246100Medicaid
FL6326530001OtherMEDICARE - DME
FL6326530001OtherMEDICARE - DME
FL65637Medicare ID - Type Unspecified