Individual
MARC THOMAS JOHANNSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
620 JOHN PAUL JONES CIR, PORTSMOUTH, VA 23708-2111
(757) 953-5000
Mailing address
1520 VINELAND CIR, UNIT B, FLEMING ISLAND, FL 32003-3298
(757) 390-1319
(855) 673-9190
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
OS15809
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
113776200
—
FL
01
—
CEFLH
BCBS
FL
01
—
PB211
MEDICARE PTAN OHRI
FL
01
—
PS103
MEDICARE PTAN OHMG
FL
Enumeration date
06/11/2008
Last updated
03/28/2023
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