Provider Demographics
NPI:1295071579
Name:JOHNSON, MARK DAVID (HSA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:HSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 WILLA SPRINGS DR
Mailing Address - Street 2:STE 110
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5205
Mailing Address - Country:US
Mailing Address - Phone:407-637-5891
Mailing Address - Fax:407-636-6205
Practice Address - Street 1:1008 WILLA SPRINGS DR
Practice Address - Street 2:STE 110
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5205
Practice Address - Country:US
Practice Address - Phone:407-637-5891
Practice Address - Fax:407-636-6205
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2511237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ8194OtherBCBS
2559432OtherCIGNA