Provider Demographics
NPI:1528690658
Name:JOHNSON, VICTORIA MAE
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NE 177TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1914
Mailing Address - Country:US
Mailing Address - Phone:786-423-7033
Mailing Address - Fax:
Practice Address - Street 1:400 NE 177TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1914
Practice Address - Country:US
Practice Address - Phone:786-423-7033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7636Medicaid