Provider Demographics
NPI:1770633612
Name:JOHNSON, MARK ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1082 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5604
Mailing Address - Country:US
Mailing Address - Phone:239-263-7399
Mailing Address - Fax:239-263-7965
Practice Address - Street 1:1082 6TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5604
Practice Address - Country:US
Practice Address - Phone:239-263-7399
Practice Address - Fax:239-263-7965
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist