Basic Information
| Provider Information | |||||||||
| NPI: | 1447403274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | IDC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | EUGENE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | IDC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2080 CHILD ST | ||||||||
| Address2: | NAVAL AIR STATION | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322145005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045423500 | ||||||||
| FaxNumber: | 9045424125 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 CHILD ST | ||||||||
| Address2: | NAVAL AIR STATION | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322145005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045423500 | ||||||||
| FaxNumber: | 9045424125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1002X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
No ID Information.