=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003556903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GBEMISOLA OLUWAKEMI JOHNSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2022
-----------------------------------------------------
Last Update Date | 10/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3817 S. SPRINGFIELD AVENUE, BOLIVAR, MO 6561 SUITE 140
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-422-4769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10901 BRIGHTON BAY BLVD NE APT 10209
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33716-3459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-714-2331
-----------------------------------------------------
Fax | 727-341-4886
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2025046442
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------