Healthcare Provider Details

I. General information

NPI: 1477590248
Provider Name (Legal Business Name): RICHARD W JOHNSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTHPARK BLVD STE 208
ST AUGUSTINE FL
32086-3129
US

IV. Provider business mailing address

200 SOUTHPARK BLVD STE 208
ST AUGUSTINE FL
32086-3129
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-1900
  • Fax: 904-826-1920
Mailing address:
  • Phone: 904-826-1900
  • Fax: 904-826-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2829
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: