MEDICARE: ISSAC OLIVER JOHNSON

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	225100000X	Physical Therapist	09345	MD
2	225X00000X	Occupational Therapist	0119006655	VA

General Provider Information

NPI Number	:	1356718076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISSAC OLIVER JOHNSON

Provider Business Mailing Address
First Line	:	1517 FULLER LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-4211
Country	:	US
Telephone Number	:	757-270-2658
Fax Number	:

Provider Business Practice Location Address
First Line	:	9160 BELVOIR WOODS PKWY
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-2703
Country	:	US
Telephone Number	:	703-781-2447
Fax Number	:

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

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	03/19/2026

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