Provider Demographics
NPI:1891439170
Name:JOHNSON, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FISHERMANS CIR APT 8
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9140
Mailing Address - Country:US
Mailing Address - Phone:386-451-9903
Mailing Address - Fax:
Practice Address - Street 1:7723 JASPER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7719
Practice Address - Country:US
Practice Address - Phone:904-725-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16615208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty