Provider Demographics
NPI:1467908988
Name:JOHNSON, TERRANCE RODERICK
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:RODERICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24110 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2240
Mailing Address - Country:US
Mailing Address - Phone:248-796-2662
Mailing Address - Fax:
Practice Address - Street 1:24110 ROSEWOOD ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2240
Practice Address - Country:US
Practice Address - Phone:248-796-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver