Provider Demographics
NPI:1033288840
Name:PERSSON, JOHN CRAIG (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CRAIG
Last Name:PERSSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ATKINSON DRIVE
Mailing Address - Street 2:STE #207
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431
Mailing Address - Country:US
Mailing Address - Phone:231-843-3600
Mailing Address - Fax:231-845-9887
Practice Address - Street 1:5 ATKINSON DRIVE
Practice Address - Street 2:STE #207
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431
Practice Address - Country:US
Practice Address - Phone:231-843-3600
Practice Address - Fax:231-845-9887
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008302207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E310390OtherBCBS
MI1155300024OtherBC BS
MI114342346Medicaid
DC1085OtherRAILROAD MEDICARE
MI1155300024OtherBC BS
MI0N99170Medicare ID - Type Unspecified