Healthcare Provider Details

I. General information

NPI: 1144252727
Provider Name (Legal Business Name): JEFFERY LEE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 7TH ST SO #500
ST PETERSBURG FL
33701-4734
US

IV. Provider business mailing address

603 7TH ST SO #500
ST PETERSBURG FL
33701-4734
US

V. Phone/Fax

Practice location:
  • Phone: 727-822-0442
  • Fax: 727-821-0416
Mailing address:
  • Phone: 727-822-0442
  • Fax: 727-821-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD59146
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME71729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: