Provider Demographics
NPI:1205820842
Name:JOHNSON, MICHEAL B (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHEAL
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 PIPER STREET, STE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-339-9455
Mailing Address - Fax:907-339-9445
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2665
Practice Address - Country:US
Practice Address - Phone:317-614-9804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-00064322085R0202X
CA20A94082085R0202X
IDO-04022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807836500Medicaid
ID1100020Medicare PIN