Provider Demographics
NPI:1114285905
Name:JOHNSON, MICHELLE RULLAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RULLAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4311
Mailing Address - Country:US
Mailing Address - Phone:617-394-7703
Mailing Address - Fax:
Practice Address - Street 1:119 WINDSOR ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3647
Practice Address - Country:US
Practice Address - Phone:617-665-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA265139261QP2300X, 314000000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility