Provider Demographics
NPI:1730145095
Name:JOHNSON, MICHAEL EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGENE
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 1:506 N RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-1622
Mailing Address - Country:US
Mailing Address - Phone:386-402-7354
Mailing Address - Fax:386-401-2337
Practice Address - Street 1:506 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1622
Practice Address - Country:US
Practice Address - Phone:386-402-7354
Practice Address - Fax:386-401-2337
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56901207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379538100Medicaid
FLE75885Medicare UPIN
FL379538100Medicaid