Healthcare Provider Details

I. General information

NPI: 1699476424
Provider Name (Legal Business Name): MARSHALL JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

240 S CRYSTAL DR
SANFORD FL
32773-4816
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone: 407-968-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: