Provider Demographics
NPI:1235209651
Name:JOHNSON, CHARLOTTE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:382 N 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2169
Mailing Address - Country:US
Mailing Address - Phone:616-396-6516
Mailing Address - Fax:616-396-2513
Practice Address - Street 1:382 N 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2169
Practice Address - Country:US
Practice Address - Phone:616-396-6516
Practice Address - Fax:616-396-2513
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3319110Medicaid
MI0410445OtherBCBS NUMBER
G46619Medicare UPIN
MI3319110Medicaid