Provider Demographics
NPI:1740240837
Name:JOHNSON, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
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:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33883
Mailing Address - Country:US
Mailing Address - Phone:863-508-0202
Mailing Address - Fax:863-293-4994
Practice Address - Street 1:320 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4113
Practice Address - Country:US
Practice Address - Phone:863-508-0202
Practice Address - Fax:863-293-4994
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36696207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060063442OtherRAILROAD MEDICARE
FL53792OtherBCBS
FL042162600Medicaid
FL77181AMedicare ID - Type Unspecified
FL042162600Medicaid