Provider Demographics
NPI:1588639520
Name:JOHNSON, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
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 1:1700 S TAMIAMI TR
Mailing Address - Street 2:SARASOTA EMERGENCY ASSOCIATES PC
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239
Mailing Address - Country:US
Mailing Address - Phone:941-917-8507
Mailing Address - Fax:941-917-8551
Practice Address - Street 1:1700 S TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-917-8507
Practice Address - Fax:941-917-8551
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82651207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00271271OtherRAILROAD MEDICARE
FL31019OtherBLUE CROSS BLUE SHIELD
G01942Medicare UPIN
FL31019OtherBLUE CROSS BLUE SHIELD