Healthcare Provider Details

I. General information

NPI: 1265979041
Provider Name (Legal Business Name): MARVIN W. JOHNSON M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E MAIN ST
LAKE BUTLER FL
32054-1353
US

IV. Provider business mailing address

PO BOX 478
LAKE BUTLER FL
32054-0478
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-2406
  • Fax: 386-496-3362
Mailing address:
  • Phone: 386-496-2406
  • Fax: 386-496-3362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0011466
License Number StateFL

VIII. Authorized Official

Name: DR. MARVIN WADE JOHNSON
Title or Position: MEDICAL DOCTOR
Credential:
Phone: 386-496-2406