Provider Demographics
NPI:1205803418
Name:JOHNSON, MARK ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
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 162264
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-2264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 RIDGEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285
Practice Address - Country:US
Practice Address - Phone:941-792-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64457207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379740600Medicaid
FL379740600Medicaid
G12771Medicare UPIN