Provider Demographics
NPI:1558477752
Name:JOHNSON, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:529 NW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2008
Mailing Address - Country:US
Mailing Address - Phone:352-331-5100
Mailing Address - Fax:
Practice Address - Street 1:6800 NW 9TH BLVD STE 4
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4253
Practice Address - Country:US
Practice Address - Phone:352-332-0902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88411174400000X
FLME884112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03008OtherBLUE CROSS / BLUE SHIELD
FL03008ZMedicare PIN