Provider Demographics
NPI:1912944984
Name:JOHNSON, SUZANNE M
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 FRUITVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-6402
Mailing Address - Country:US
Mailing Address - Phone:941-909-7847
Mailing Address - Fax:844-388-6186
Practice Address - Street 1:5309 FRUITVILLE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6402
Practice Address - Country:US
Practice Address - Phone:941-909-7847
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068401207Q00000X
OH35.068401208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0155602Medicaid
OHG12554Medicare UPIN
OHKA0695513Medicare ID - Type UnspecifiedMILAN
OH0155602Medicaid