Healthcare Provider Details

I. General information

NPI: 1124964267
Provider Name (Legal Business Name): VINCENT VESHAWN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9623 PARKVIEW AVE
CLEVELAND OH
44104-4703
US

IV. Provider business mailing address

9623 PARKVIEW AVE
CLEVELAND OH
44104-4703
US

V. Phone/Fax

Practice location:
  • Phone: 216-538-9802
  • Fax:
Mailing address:
  • Phone: 380-266-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1629690920
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: