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
State | License ID | Taxonomies |
---|---|---|
FL | ME56901 | 207RC0000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 379538100 | Medicaid | |
FL | E75885 | Medicare UPIN | |
FL | 379538100 | Medicaid |