Provider Demographics
NPI:1205847209
Name:JOHNSON, MICHAEL ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
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 1:108 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-763-2253
Mailing Address - Fax:707-763-7030
Practice Address - Street 1:108 LYNCH CREEK WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-763-2253
Practice Address - Fax:707-763-7030
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3671213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA480027344OtherRAILROAD MEDICARE
CA000E36712OtherMEDICAL
CA000E36712Medicaid
CA000E36712Medicaid
CAHH674ZMedicare PIN
CA000E36712OtherMEDICAL
CA1274880001Medicare NSC