MEDICARE: DR. LAURA LYNN 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	208D00000X	General Practice Physician	ME78173	FL
2	208000000X	Pediatrics Physician	ME78173	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

General Provider Information

NPI Number	:	1588729891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA LYNN JOHNSON M.D.

Provider Business Mailing Address
First Line	:	10140 CENTURION PKWY N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0532
Country	:	US
Telephone Number	:	904-697-4127
Fax Number	:	904-697-5102

Provider Business Practice Location Address
First Line	:	840 37TH PL
Second Line	:	STE 1N
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6502
Country	:	US
Telephone Number	:	772-978-9000
Fax Number	:	772-978-9922

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/21/2022

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