Provider Demographics
NPI:1871503607
Name:JOHNSON, WALTER G (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 11406
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4005
Mailing Address - Country:US
Mailing Address - Phone:321-452-3811
Mailing Address - Fax:321-454-4026
Practice Address - Street 1:150 N SYKES CREEK PKWY
Practice Address - Street 2:# 300
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3488
Practice Address - Country:US
Practice Address - Phone:321-452-3811
Practice Address - Fax:321-454-4026
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56254207RC0000X, 207RI0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069823700Medicaid
FLC17480Medicare UPIN
FL069823700Medicaid