Provider Demographics
NPI:1669527727
Name:GENNETT JOHNSON, MD
Entity type:Organization
Organization Name:GENNETT JOHNSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-616-0239
Mailing Address - Street 1:PO BOX 22948
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32830-2948
Mailing Address - Country:US
Mailing Address - Phone:407-616-0239
Mailing Address - Fax:407-876-2869
Practice Address - Street 1:9068 GREAT HERON CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32836-5483
Practice Address - Country:US
Practice Address - Phone:407-616-0239
Practice Address - Fax:407-876-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 47316207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061741500Medicaid
FL14151OtherBCBS
FL14151OtherBCBS
FL061741500Medicaid