Provider Demographics
NPI:1205809746
Name:JOHNSON, MITCHELL W (PA)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 7TH TER
Mailing Address - Street 2:#101
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6553
Mailing Address - Country:US
Mailing Address - Phone:772-567-6602
Mailing Address - Fax:772-567-7754
Practice Address - Street 1:3770 7TH TER
Practice Address - Street 2:#101
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6553
Practice Address - Country:US
Practice Address - Phone:772-567-6602
Practice Address - Fax:772-567-7754
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2767363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL970009579OtherRAILROAD MEDICARE PROV#
FLY02C0OtherBLUE CROSS BLUE SHIELD
FL88572Medicare UPIN
FLY02C0OtherBLUE CROSS BLUE SHIELD