Provider Demographics
NPI:1467450304
Name:JOHNSON, JAMES EDWARD (DO)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
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 1:37400 GARFIELD RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3648
Mailing Address - Country:US
Mailing Address - Phone:586-228-3800
Mailing Address - Fax:586-228-9800
Practice Address - Street 1:37400 GARFIELD RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-3648
Practice Address - Country:US
Practice Address - Phone:586-228-3800
Practice Address - Fax:586-228-9800
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007081208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2125953Medicaid
MIE26084Medicare UPIN
MI2125953Medicaid