Basic Information
| Provider Information | |||||||||
| NPI: | 1518042415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TIRRELL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | ME88326 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | ME88326 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | LF24447 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 268655400 | 05 | FL | MEDICAID |