Healthcare Provider Details

I. General information

NPI: 1184695710
Provider Name (Legal Business Name): KEITH B JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 E VENICE AVE SUITE 202
VENICE FL
34285-9082
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 941-480-0500
  • Fax: 941-480-9322
Mailing address:
  • Phone: 877-856-3774
  • Fax: 941-480-9322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME58404
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME58404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: