Healthcare Provider Details

I. General information

NPI: 1760595904
Provider Name (Legal Business Name): VICTORIA S JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 COMMERCIAL CT STE A
VENICE FL
34292-1651
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-261-0010
  • Fax: 941-261-0011
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME153040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: