Provider Demographics
NPI:1316911670
Name:JOHNSON, GORDON LESLIE (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:LESLIE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 W FOREST HILL BLVD
Mailing Address - Street 2:WELLINGTON REGIONAL MEDICAL CENTER PATHOLOGY DEPT
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-798-8559
Mailing Address - Fax:561-798-8645
Practice Address - Street 1:10101 W FOREST HILL BLVD
Practice Address - Street 2:WELLINGTON REGIONAL MEDICAL CENTER PATHOLOGY DEPT
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-798-8559
Practice Address - Fax:561-798-8645
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063120207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE56148Medicare UPIN
FLE6520ZMedicare PIN