Basic Information
| Provider Information | |||||||||
| NPI: | 1538150610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | LAROCHE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAM | ||||||||
| OtherFirstName: | DIANNE | ||||||||
| OtherMiddleName: | LAROCHE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD. S. | ||||||||
| Address2: | BLDG. 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322160000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Practice Location | |||||||||
| Address1: | 3599 UNIVERSITY BLVD. S. | ||||||||
| Address2: | BLDG. 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322160000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2005 | ||||||||
| LastUpdateDate: | 08/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME93196 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00319147 | 01 | GA | RAILROAD MEDICARE | OTHER | 109749741A | 05 | GA | MEDICAID | 275351100 | 05 | FL | MEDICAID |