Provider Demographics
NPI:1063407237
Name:JOHNSON, NINA F (MD)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:F
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:FUKUNAGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2134
Mailing Address - Country:US
Mailing Address - Phone:321-841-1893
Mailing Address - Fax:321-841-3794
Practice Address - Street 1:1400 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:321-841-1893
Practice Address - Fax:321-841-3794
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010469392085R0001X
MI43010535542085R0001X
FLME1710992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063407237Medicaid
IN200129810Medicaid
IN728230XXMedicare ID - Type Unspecified