Provider Demographics
NPI:1235706649
Name:JOHNSON, CARMEN (DPM)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28050 GRAND RIVER AVE.
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28050 GRAND RIVER AVE.
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336
Practice Address - Country:US
Practice Address - Phone:678-634-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5951001436213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery