Healthcare Provider Details

I. General information

NPI: 1063407237
Provider Name (Legal Business Name): NINA F JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NINA FUKUNAGA

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 12/23/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-1893
  • Fax: 321-841-3794
Mailing address:
  • Phone: 321-841-1893
  • Fax: 321-841-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01046939
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4301053554
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME171099
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: