Provider Demographics
NPI:1245344571
Name:JOHNSON, JESSE WAYNE JR (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:JR
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 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-333-2273
Mailing Address - Fax:407-333-3939
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2273
Practice Address - Fax:407-333-3939
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 49038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAM199OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER
FLPTAN DN9084OtherMEDICARE RR
FL4308871OtherCIGNA
FL0004104041OtherAETNA
FL04163OtherBLUE CROSS BLUE SHIELD
D45773Medicare UPIN
FL4308871OtherCIGNA