Provider Demographics
NPI:1639155633
Name:JOHNSON, JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
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 1:7225 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2908
Mailing Address - Country:US
Mailing Address - Phone:954-341-9771
Mailing Address - Fax:954-341-9772
Practice Address - Street 1:7225 N UNIVERSITY DR
Practice Address - Street 2:STE 104
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2908
Practice Address - Country:US
Practice Address - Phone:954-341-9771
Practice Address - Fax:954-341-9772
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43407208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044637800Medicaid
61544OtherBLUE CROSS BLUE SHIELD
FL0072480OtherGHI
FL0163191OtherGHI
FL208508OtherAVMED
D57273Medicare UPIN
FL208508OtherAVMED
FL044637800Medicaid