Healthcare Provider Details

I. General information

NPI: 1780767616
Provider Name (Legal Business Name): PAUL M JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2781
US

IV. Provider business mailing address

1401 25TH ST S
GREAT FALLS MT
59405-6010
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4267
  • Fax: 386-425-4879
Mailing address:
  • Phone: 406-731-8888
  • Fax: 406-731-8876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME160203
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberME160203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: