Provider Demographics
NPI:1144252727
Name:JOHNSON, JEFFERY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 7TH ST SO
Mailing Address - Street 2:#500
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4734
Mailing Address - Country:US
Mailing Address - Phone:727-822-0442
Mailing Address - Fax:727-821-0416
Practice Address - Street 1:603 7TH ST SO
Practice Address - Street 2:#500
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4734
Practice Address - Country:US
Practice Address - Phone:727-822-0442
Practice Address - Fax:727-821-0416
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD59146208600000X
FLME71729208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404698600Medicaid
MD1591Medicare PIN
MDG99153Medicare UPIN
MDP00146730Medicare PIN
MD404698600Medicaid