Healthcare Provider Details

I. General information

NPI: 1205820842
Provider Name (Legal Business Name): MICHEAL B. JOHNSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 N DALE MABRY HWY
TAMPA FL
33614-2665
US

IV. Provider business mailing address

3650 PIPER STREET, STE A
ANCHORAGE AK
99508
US

V. Phone/Fax

Practice location:
  • Phone: 317-614-9804
  • Fax:
Mailing address:
  • Phone: 907-339-9455
  • Fax: 907-339-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC2-0006432
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20A9408
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberO-0402
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: