Provider Demographics
NPI:1346262821
Name:JOHNSON, JO ANN (DO)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 W SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1374
Mailing Address - Country:US
Mailing Address - Phone:810-750-1763
Mailing Address - Fax:810-750-1786
Practice Address - Street 1:3220 W SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1374
Practice Address - Country:US
Practice Address - Phone:810-750-1763
Practice Address - Fax:810-750-1786
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010026207Q00000X, 146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301746Medicaid
MI4301746Medicaid
MIE26083Medicare UPIN