Basic Information
| Provider Information | |||||||||
| NPI: | 1992910301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022987371 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 6535 NEMOURS PARKWAY | ||||||||
| Address2: | NCH | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332827884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | C20010119 | DE | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 53505 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 235491 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | OS11789 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085P0229X | OS11789 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 006252800 | 05 | FL | MEDICAID |