Provider Demographics
NPI:1932835717
Name:MORAES, JOHNNY CLARK
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:CLARK
Last Name:MORAES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 SW 67TH AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3283
Mailing Address - Country:US
Mailing Address - Phone:954-658-4561
Mailing Address - Fax:
Practice Address - Street 1:4199 SW 67TH AVE APT 201
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3283
Practice Address - Country:US
Practice Address - Phone:954-658-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program