Healthcare Provider Details

I. General information

NPI: 1043874225
Provider Name (Legal Business Name): GEORGE MICHAEL JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 MASSEY AVENUE
JACKSONVILLE FL
32228
US

IV. Provider business mailing address

7751 LISA DR E
JACKSONVILLE FL
32217-4134
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-4265
  • Fax:
Mailing address:
  • Phone: 615-815-4834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS19146
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: