Provider Demographics
NPI:1417083189
Name:JOHNSON, PAMELA D (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:KARMANOS CANCER CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8699
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048870208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4133392OtherAETNA
MAB8910OtherMCARE
MI2422609003OtherCIGNA
MA0633185OtherBCBS
MI102263OtherPREFERRED CHOICES
MA74717AOtherHEALTH ALLIANCE PLAN
MIP71138OtherBLUE CHOICE
MIP71138OtherBLUE CHOICE
MI4133392OtherAETNA
MI0P30630636Medicare PIN