Healthcare Provider Details

I. General information

NPI: 1386637700
Provider Name (Legal Business Name): DONALD CHARLES JOHNSON JR. DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 OSCEOLA AVE
ORMOND BEACH FL
32176-6638
US

IV. Provider business mailing address

233 OSCEOLA AVE
ORMOND BEACH FL
32176-6638
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-6424
  • Fax: 386-672-5251
Mailing address:
  • Phone: 386-672-6424
  • Fax: 386-672-5251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO-2558
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-2558
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: