Provider Demographics
NPI:1245236215
Name:JOHNSON, BRUCE G (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:G
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:36123 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2643592Medicaid
MI2608252Medicaid
MI2832400Medicaid
MI2643592Medicaid
MI0E06249Medicare ID - Type Unspecified
MIE25559Medicare UPIN
MI2643592Medicaid