Provider Demographics
NPI:1710983747
Name:JOHNSON, STEPHEN D (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 GRIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-6760
Mailing Address - Country:US
Mailing Address - Phone:863-859-0335
Mailing Address - Fax:863-859-0501
Practice Address - Street 1:2390 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-6760
Practice Address - Country:US
Practice Address - Phone:863-859-0335
Practice Address - Fax:863-859-0501
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5721111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22244YMedicare PIN
T88111Medicare UPIN
FL350050798Medicare PIN