Provider Demographics
NPI:1497751929
Name:JOHNSON, JULIE K (DO)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 N SPIDER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8440
Mailing Address - Country:US
Mailing Address - Phone:231-947-0673
Mailing Address - Fax:801-740-2847
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:801-740-2847
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011139207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI930018880OtherRAILROAD MEDICARE
MI3064262Medicaid
MIJJ011139OtherBLUE CROSS BLUE SHIELD
MI930018880OtherRAILROAD MEDICARE
MI0B86032013Medicare Oscar/Certification