Ian James Johnson, M.D.
Individual provider Active NPI Pediatric Adolescent Medicine Physician · Patrick Afb, FL
NPI 1265404990 · NPPES record last updated Jun 25, 2009
Key facts
- NPI
- 1265404990
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Adolescent Medicine Physician 2080A0000X
- License
- G0440 (TX)
- Practice address
- 1381 South Patrick Dr, Patrick Afb
45 Medical Group
Patrick Afb, FL 32925-4162 - Phone
- (321) 494-8152
- Fax
- (321) 494-8533
- NPI assigned
- Feb 6, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G0440 | TX | MD | Pediatric Adolescent Medicine Physician |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Adolescent Medicine Physician | 2080A0000X | G0440 | TX | Yes |
Addresses
Primary practice location
1381 South Patrick Dr, Patrick Afb
45 Medical Group
Patrick Afb, FL 32925-4162
Mailing address
4066 Hield Rd NW
Palm Bay, FL 32907-6307
Phone (321) 674-0932
Other providers in Patrick Afb, FL
- Kirby Glen Harvey Jr.
- Brianna Hassett
- Sheri Lynn Hunt
- Frances Jeffcoat
- Justin L Jennings
- Sondra Adele Long
- Rhonda Mangione
- Naquita Jackson Manning
- Lisa R Martin
- Gabriela Martinez
All providers in Patrick Afb, FL · Pediatric Adolescent Medicine Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 25, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.