Provider Demographics
NPI:1629232301
Name:JOHNSON, MICHELE RENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:RENE
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:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:410 CELEBRATION PL STE 208
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5434
Practice Address - Country:US
Practice Address - Phone:074-566-2229
Practice Address - Fax:407-566-2499
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015739600Medicaid
FLJB324ZOtherMEDICARE