Provider Demographics
NPI:1497712384
Name:JOHNSON, DOUGLAS WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 19675
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9675
Mailing Address - Country:US
Mailing Address - Phone:904-309-8680
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:7015 A C SKINNER PKWY BLDG 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6932
Practice Address - Country:US
Practice Address - Phone:904-516-3737
Practice Address - Fax:904-516-3738
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME434062085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03911OtherBCBS
FLAJ038SOtherMEDICARE PTAN
FLP00191285OtherMEDICARE RAILROAD
FL040225OtherAVMED
GA853120709AMedicaid
FL046276400Medicaid
FL03911PMedicare PIN
FL03911JMedicare PIN
FL03911NMedicare PIN
FL03911SMedicare PIN
KY0169Medicare PIN
FLP00191285OtherMEDICARE RAILROAD
FL03911MMedicare PIN
FL046276400Medicaid
GA92BBFVVMedicare PIN
FL03911OtherBCBS
FL03911LMedicare PIN
FL03911KMedicare PIN
FLAJ038YMedicare PIN
FLAJ038ZMedicare PIN