Provider Demographics
NPI:1265404990
Name:JOHNSON, IAN JAMES (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:JAMES
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 1:4066 HIELD RD NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-6307
Mailing Address - Country:US
Mailing Address - Phone:321-674-0932
Mailing Address - Fax:321-674-6200
Practice Address - Street 1:1381 SOUTH PATRICK DR, PATRICK AFB
Practice Address - Street 2:45 MEDICAL GROUP
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-4162
Practice Address - Country:US
Practice Address - Phone:321-494-8152
Practice Address - Fax:321-494-8533
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG04402080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine