1003556903 NPI number — DR. GBEMISOLA OLUWAKEMI JOHNSON MD

Table of content: DR. GBEMISOLA OLUWAKEMI JOHNSON MD (NPI 1003556903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003556903 NPI number — DR. GBEMISOLA OLUWAKEMI JOHNSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
GBEMISOLA
Provider Middle Name:
OLUWAKEMI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003556903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10901 BRIGHTON BAY BLVD NE APT 10209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33716-3459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-714-2331
Provider Business Mailing Address Fax Number:
727-341-4886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3817 S. SPRINGFIELD AVENUE, BOLIVAR, MO 6561
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-422-4769
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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