Provider Demographics
NPI:1811913866
Name:JOHNSON, PHILIP NATHANIEL (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:NATHANIEL
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 1:2230 SW 19TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-1391
Mailing Address - Country:US
Mailing Address - Phone:352-237-4133
Mailing Address - Fax:352-237-7728
Practice Address - Street 1:2701 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6303
Practice Address - Country:US
Practice Address - Phone:813-738-6690
Practice Address - Fax:813-816-0326
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66825207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379110600Medicaid
FL379110600Medicaid
FL26837XMedicare ID - Type UnspecifiedGROUP ID# K3953