Provider Demographics
NPI:1548220700
Name:JOHNSON, CLARK PETER (DPM)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:PETER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3430
Mailing Address - Country:US
Mailing Address - Phone:269-968-6000
Mailing Address - Fax:269-968-3015
Practice Address - Street 1:213 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3430
Practice Address - Country:US
Practice Address - Phone:269-968-6000
Practice Address - Fax:269-968-3015
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000962213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4851350000OtherBCBSM
MI0980190001OtherADMINASTAR DMERC
MI5212079OtherAETNA
MI1342674Medicaid
MI2730002OtherPHP IBA
MI121508OtherPREFERRED CHOICES
MIP53895OtherBLUE CARE NETWORK
MI121508OtherPREFERRED CHOICES
MI5212079OtherAETNA