Provider Demographics
NPI:1265979041
Name:MARVIN W. JOHNSON M.D.
Entity type:Organization
Organization Name:MARVIN W. JOHNSON M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-496-2406
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-0478
Mailing Address - Country:US
Mailing Address - Phone:386-496-2406
Mailing Address - Fax:386-496-3362
Practice Address - Street 1:850 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1353
Practice Address - Country:US
Practice Address - Phone:386-496-2406
Practice Address - Fax:386-496-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0011466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53331OtherBCBS
FL065935500Medicaid
FLD64469Medicare UPIN
FL53331OtherBCBS