Provider Demographics
NPI:1336136753
Name:JOHNSON, CARL A (DO)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30550 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-1528
Mailing Address - Country:US
Mailing Address - Phone:586-771-0290
Mailing Address - Fax:586-771-5450
Practice Address - Street 1:30550 UTICA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-1528
Practice Address - Country:US
Practice Address - Phone:586-771-0290
Practice Address - Fax:586-771-5450
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007868207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE25608Medicare UPIN