Provider Demographics
NPI:1780642645
Name:JOHNSON, DIANA L (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name: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 1:1215 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6330
Mailing Address - Country:US
Mailing Address - Phone:904-757-1998
Mailing Address - Fax:904-696-7462
Practice Address - Street 1:1215 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6330
Practice Address - Country:US
Practice Address - Phone:904-757-1998
Practice Address - Fax:904-696-7462
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87746208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH96107Medicare UPIN
U1607ZMedicare ID - Type Unspecified