Provider Demographics
NPI:1043482797
Name:JOHNSON, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 SOUTHERN BLVD STE 5200
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1275
Mailing Address - Country:US
Mailing Address - Phone:937-435-8966
Mailing Address - Fax:937-435-8966
Practice Address - Street 1:3533 SOUTHERN BLVD STE 5200
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1275
Practice Address - Country:US
Practice Address - Phone:937-435-8663
Practice Address - Fax:937-435-8966
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35092049208C00000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2849412Medicaid