Healthcare Provider Details

I. General information

NPI: 1538329644
Provider Name (Legal Business Name): MARC THOMAS JOHANNSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

1520 VINELAND CIR UNIT B
FLEMING ISLAND FL
32003-3298
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5000
  • Fax:
Mailing address:
  • Phone: 757-390-1319
  • Fax: 855-673-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS15809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: