MEDICARE: DR. VANESSA G KING-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	174400000X	Specialist	ME78684	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750320057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VANESSA G KING-JOHNSON M.D.

Provider Business Mailing Address
First Line	:	4298 5TH AVE
Second Line	:
City	:	MARIANNA
State	:	FL
Zip	:	32446-2173
Country	:	US
Telephone Number	:	850-482-5787
Fax Number	:	850-482-8108

Provider Business Practice Location Address
First Line	:	4298 5TH AVE
Second Line	:
City	:	MARIANNA
State	:	FL
Zip	:	32446-2173
Country	:	US
Telephone Number	:	850-482-5787
Fax Number	:	850-482-8108

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	09/08/2010

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