Healthcare Provider Details

I. General information

NPI: 1306944129
Provider Name (Legal Business Name): MICHELLE L JOHNSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 58TH ST N
CLEARWATER FL
33760-9900
US

IV. Provider business mailing address

14100 58TH ST N
CLEARWATER FL
33760-9900
US

V. Phone/Fax

Practice location:
  • Phone: 954-467-4822
  • Fax: 954-760-7798
Mailing address:
  • Phone: 727-824-8181
  • Fax: 727-824-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: