Basic Information
| Provider Information | |||||||||
| NPI: | 1407007552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASHINGTON | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831010 | ||||||||
| FaxNumber: | 9042443457 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831010 | ||||||||
| FaxNumber: | 9042443457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207XX0005X | 64298 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | ME133343 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003150119L | 05 | GA | MEDICAID | 003150119D | 05 | GA | MEDICAID | 003150119I | 05 | GA | MEDICAID | 02427208 | 01 | GA | AMERIGROUP | OTHER | 003150119C | 05 | GA | MEDICAID | 003150119G | 05 | GA | MEDICAID | 003150119J | 05 | GA | MEDICAID | 1023416 | 01 | WELLCARE | OTHER | 003150119E | 05 | GA | MEDICAID | 003150119H | 05 | GA | MEDICAID | 003150119K | 05 | GA | MEDICAID | 0532272 | 01 | GA | CIGNA | OTHER | 003150119F | 05 | GA | MEDICAID | 202I208229 | 01 | GA | MEDICARE | OTHER | 003150119A | 05 | GA | MEDICAID | 003150119B | 05 | GA | MEDICAID |