Provider Demographics
NPI:1306944129
Name:JOHNSON, MICHELLE L (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 58TH ST N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-9900
Mailing Address - Country:US
Mailing Address - Phone:727-824-8181
Mailing Address - Fax:727-824-8165
Practice Address - Street 1:14100 58TH ST N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-9900
Practice Address - Country:US
Practice Address - Phone:954-467-4822
Practice Address - Fax:954-760-7798
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258166300Medicaid
FL258166300Medicaid
FL47262WMedicare ID - Type UnspecifiedPROVIDER #