Provider Demographics
NPI:1568925394
Name:JOHNSON, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 SW 160TH AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6314
Mailing Address - Country:US
Mailing Address - Phone:954-399-4673
Mailing Address - Fax:
Practice Address - Street 1:325 SENTRY PKWY E BLDG 5W
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2312
Practice Address - Country:US
Practice Address - Phone:954-399-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS021752208D00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty