Healthcare Provider Details

I. General information

NPI: 1194302828
Provider Name (Legal Business Name): ELI JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORANGE FL
32803-1248
US

IV. Provider business mailing address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

V. Phone/Fax

Practice location:
  • Phone: 614-544-4691
  • Fax: 614-544-1745
Mailing address:
  • Phone: 407-303-6413
  • Fax: 614-544-1745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.017160
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS20042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: