MEDICARE: DR. CORY JOHNSON PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT37672	FL

General Provider Information

NPI Number	:	1174283535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORY JOHNSON PT, DPT

Provider Business Mailing Address
First Line	:	12772 LOW TIDE DR UNIT 335
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1627
Country	:	US
Telephone Number	:	813-300-2354
Fax Number	:

Provider Business Practice Location Address
First Line	:	12772 LOW TIDE DR UNIT 335
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1627
Country	:	US
Telephone Number	:	813-300-2354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2021
Last Update Date	:	12/28/2021

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