Provider Demographics
NPI:1992999122
Name:JOHNSON, CHARLES ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 CLINT MOORE RD
Mailing Address - Street 2:SUITE NUMBER 155
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2768
Mailing Address - Country:US
Mailing Address - Phone:561-338-0700
Mailing Address - Fax:561-362-9960
Practice Address - Street 1:1601 CLINT MOORE RD
Practice Address - Street 2:155
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2768
Practice Address - Country:US
Practice Address - Phone:561-338-0700
Practice Address - Fax:561-362-9960
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0004672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE32288Medicare PIN