Provider Demographics
NPI:1588648265
Name:JOHNSON, JERRI L (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRI
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MAITLAND AVE
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5448
Mailing Address - Country:US
Mailing Address - Phone:407-260-2606
Mailing Address - Fax:407-260-6339
Practice Address - Street 1:411 MAITLAND AVE
Practice Address - Street 2:SUITE 1001
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5448
Practice Address - Country:US
Practice Address - Phone:407-260-2606
Practice Address - Fax:407-260-6339
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058049000Medicaid
FL12752Medicare ID - Type Unspecified
FLE95275Medicare UPIN