Provider Demographics
NPI:1942695416
Name:JOHNSON, JEFFREY DAVID II
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:II
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:PO BOX 100264
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0264
Mailing Address - Country:US
Mailing Address - Phone:352-273-5199
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-1521
Practice Address - Country:US
Practice Address - Phone:352-273-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150300207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110611200Medicaid