MEDICARE: IAN JAMES JOHNSON M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	G0440	TX

General Provider Information

NPI Number	:	1265404990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN JAMES JOHNSON M.D.

Provider Business Mailing Address
First Line	:	4066 HIELD RD NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-6307
Country	:	US
Telephone Number	:	321-674-0932
Fax Number	:	321-674-6200

Provider Business Practice Location Address
First Line	:	1381 SOUTH PATRICK DR, PATRICK AFB
Second Line	:	45 MEDICAL GROUP
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-4162
Country	:	US
Telephone Number	:	321-494-8152
Fax Number	:	321-494-8533

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

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	06/25/2009

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