Healthcare Provider Details

I. General information

NPI: 1760743751
Provider Name (Legal Business Name): CRYSTAL JOHNSON-MANN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL JOHNSON M.D.

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0109
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL34777
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101261806
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: