Provider Demographics
NPI:1194953695
Name:JOHNSON, SUZANNE SANDRA (DO)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:SANDRA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:SANDRA
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1120 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4134
Mailing Address - Country:US
Mailing Address - Phone:727-789-2922
Mailing Address - Fax:941-847-7919
Practice Address - Street 1:1120 10TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-4134
Practice Address - Country:US
Practice Address - Phone:941-847-7903
Practice Address - Fax:941-847-7919
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLN/A207Q00000X
FLOS10891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022946300Medicaid
FLOS10891OtherMEDICAL LICENSE NUMBER