Provider Demographics
NPI:1497282065
Name:JOHNSON, MICHAEL E (BS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 S HIGHWAY 69
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-9310
Mailing Address - Country:US
Mailing Address - Phone:918-708-3006
Mailing Address - Fax:
Practice Address - Street 1:2109 S HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-9310
Practice Address - Country:US
Practice Address - Phone:918-708-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator