Provider Demographics
NPI:1790774255
Name:JOHNSON, TERRIE M (MD)
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:M
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 1:900 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:561-863-5757
Mailing Address - Fax:861-863-6627
Practice Address - Street 1:2939 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2916
Practice Address - Country:US
Practice Address - Phone:561-863-5757
Practice Address - Fax:561-863-6627
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87569208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
291325OtherAVMED
5720771OtherAETNA
FL268732100Medicaid
82186OtherBLUECROSS BLUESHIELD
FL268732100Medicaid