Provider Demographics
NPI:1891732814
Name:JOHN, JOHNATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:B
Last Name:JOHN
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 1:1300 SAWGRASS CORPORATE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2826
Mailing Address - Country:US
Mailing Address - Phone:727-322-4830
Mailing Address - Fax:813-870-0100
Practice Address - Street 1:3003 W DR MLK BLVD
Practice Address - Street 2:3RD FLOOR MAB
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:727-322-4830
Practice Address - Fax:813-870-0100
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL777552080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270521400Medicaid
FL48297ZMedicare ID - Type Unspecified
FL270521400Medicaid