MEDICARE: MR. ANDRE 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	172A00000X	Driver

General Provider Information

NPI Number	:	1588228399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDRE JOHNSON

Provider Business Mailing Address
First Line	:	PO BOX 4953
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33758-4953
Country	:	US
Telephone Number	:	813-455-7609
Fax Number	:

Provider Business Practice Location Address
First Line	:	1368 S WASHINGTON AVE
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33756-6503
Country	:	US
Telephone Number	:	813-455-7609
Fax Number	:

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

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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