MEDICARE: DR. CHERYL DIANE JOHNSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	ME117062	FL
2	207R00000X	Internal Medicine Physician	ME117062	FL
3	208000000X	Pediatrics Physician	ME117062	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4160665	OTHER	TN	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114923414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHERYL DIANE JOHNSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-343-2052
Fax Number	:	239-343-5348

Provider Business Practice Location Address
First Line	:	9981 S HEALTHPARK DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3618
Country	:	US
Telephone Number	:	239-343-2052
Fax Number	:	239-343-5348

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	08/22/2024

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Directions to “ DR. CHERYL DIANE JOHNSON M.D.” Practice Location

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