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General NPI Number Information
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NPI Number | 1700109915
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Entity Type | Organization
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Legal Business Name | JOHNNIE R DEGRAW INC
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Dates
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Enumeration Date | 03/03/2010
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Last Update Date | 10/01/2020
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Provider Practice Location Address
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Address Line | 5915 W GULF TO LAKE HWY
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-7565
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Country | US
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Telephone | 352-794-3872
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Fax | 352-794-3876
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Provider Business Mailing Address
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Address Line | 5915 W GULF TO LAKE HWY
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-7565
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Country | US
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Telephone | 352-794-3872
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Fax | 352-794-3876
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Authorized Official
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Title or Position | OWNER
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Name | JOHNNIE R DEGRAW
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Credential | MD
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Telephone | 352-794-3872
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA2646
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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