Provider Demographics
NPI:1114968443
Name:JOHNSON, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
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 1:4410 WATERMELON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5204
Mailing Address - Country:US
Mailing Address - Phone:205-345-1520
Mailing Address - Fax:205-345-1761
Practice Address - Street 1:4410 WATERMELON RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5204
Practice Address - Country:US
Practice Address - Phone:205-345-1520
Practice Address - Fax:205-345-1761
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007004207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051043258OtherBCBS AL
AL000043258Medicaid
AL51043258Medicare ID - Type Unspecified
C71864Medicare UPIN