Provider Demographics
NPI:1962666966
Name:GURGEN, JOHNNY (DO)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:GURGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 ROLLING ACRES RD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5029
Mailing Address - Country:US
Mailing Address - Phone:352-435-7695
Mailing Address - Fax:352-435-7453
Practice Address - Street 1:920 ROLLING ACRES RD UNIT 203
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5029
Practice Address - Country:US
Practice Address - Phone:352-435-7695
Practice Address - Fax:352-435-7453
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10423207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery