Provider Demographics
NPI:1700109915
Name:JOHNNIE R DEGRAW INC
Entity Type:Organization
Organization Name:JOHNNIE R DEGRAW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-794-3872
Mailing Address - Street 1:5915 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7565
Mailing Address - Country:US
Mailing Address - Phone:352-794-3872
Mailing Address - Fax:352-794-3876
Practice Address - Street 1:5915 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7565
Practice Address - Country:US
Practice Address - Phone:352-794-3872
Practice Address - Fax:352-794-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363LA2200X
FLPA2646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6450130001Medicare NSC
FLCY740AMedicare PIN