Provider Demographics
NPI:1770856833
Name:JOHNNY GURGEN DO PA
Entity type:Organization
Organization Name:JOHNNY GURGEN DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GURGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-435-7695
Mailing Address - Street 1:920 ROLLING ACRES RD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5029
Mailing Address - Country:US
Mailing Address - Phone:352-435-7695
Mailing Address - Fax:352-435-7453
Practice Address - Street 1:920 ROLLING ACRES RD UNIT 203
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5029
Practice Address - Country:US
Practice Address - Phone:352-435-7695
Practice Address - Fax:352-435-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGB446AMedicare PIN