Provider Demographics
NPI:1154314433
Name:JOHNSON, DOUGLAS PHILIP (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PHILIP
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E SAGINAW ST
Mailing Address - Street 2:STE 111
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-4775
Mailing Address - Country:US
Mailing Address - Phone:517-351-7640
Mailing Address - Fax:517-351-9462
Practice Address - Street 1:3401 E SAGINAW ST
Practice Address - Street 2:STE 111
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4775
Practice Address - Country:US
Practice Address - Phone:517-351-7640
Practice Address - Fax:517-351-9462
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000788213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4135743Medicaid
T33979Medicare UPIN
5335574Medicare ID - Type Unspecified