Provider Demographics
NPI:1437178795
Name:JOHNSON, REBA E (MD)
Entity Type:Individual
Prefix:
First Name:REBA
Middle Name:E
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 1:5701 BOW POINTE DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-384-8310
Mailing Address - Fax:248-384-8312
Practice Address - Street 1:5701 BOW POINTE DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3199
Practice Address - Country:US
Practice Address - Phone:248-384-8310
Practice Address - Fax:248-384-8312
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301082354207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RJ082354OtherCHAMPUS-CHAMPUS
MI1108205911OtherBCBS IND PIN
700H262220OtherBLUE CROSS-BLUE CROSS
MI1437178795Medicaid
MI488422710Medicaid
RJ082354OtherCOMMERCIAL-COMMERCIAL NUMBER
I69657Medicare UPIN
MI4989341Medicare PIN
MI4989341Medicare PIN