Provider Demographics
NPI:1386616795
Name:JOHNSON, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:900 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4368
Mailing Address - Country:US
Mailing Address - Phone:904-249-0335
Mailing Address - Fax:904-249-0347
Practice Address - Street 1:900 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4368
Practice Address - Country:US
Practice Address - Phone:904-249-0335
Practice Address - Fax:904-249-0347
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2543737-00Medicaid
FL2543737-00Medicaid
FL43771YMedicare PIN