Provider Demographics
NPI:1750320057
Name:KING-JOHNSON, VANESSA G (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:G
Last Name:KING-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 1:4298 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2173
Mailing Address - Country:US
Mailing Address - Phone:850-482-5787
Mailing Address - Fax:850-482-8108
Practice Address - Street 1:4298 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2173
Practice Address - Country:US
Practice Address - Phone:850-482-5787
Practice Address - Fax:850-482-8108
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270213400Medicaid
47685ZMedicare ID - Type Unspecified
FL270213400Medicaid