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General NPI Number Information
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NPI Number | 1245344571
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Entity Type | Individual
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Provider Name | JESSE WAYNE JOHNSON JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 03/30/2015
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Provider Practice Location Address
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Address Line | 4106 W LAKE MARY BLVD SUITE 100
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City | LAKE MARY
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State | FL
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Zip | 32746-3315
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Country | US
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Telephone | 407-333-2273
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Fax | 407-333-3939
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Provider Business Mailing Address
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Address Line | 4106 W LAKE MARY BLVD SUITE 100
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City | LAKE MARY
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State | FL
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Zip | 32746-3315
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Country | US
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Telephone | 407-333-2273
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Fax | 407-333-3939
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME 49038
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License Number State | FL
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