=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629632989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OSIRIS JOHNSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2019
-----------------------------------------------------
Last Update Date | 11/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20900 BISCAYNE BLVD STE 821
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-470-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28802 RAINDANCE AVE
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33543-6422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-470-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | T7255
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------