Provider Demographics
NPI:1861463788
Name:JOHANSEN, ROBERT LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LANCE
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:LANCE
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3484
Mailing Address - Country:US
Mailing Address - Phone:228-328-2400
Mailing Address - Fax:228-328-4200
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3484
Practice Address - Country:US
Practice Address - Phone:228-328-2400
Practice Address - Fax:228-328-4200
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14698207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5707330001OtherNSC
MS00116678Medicaid
MS00116678Medicaid