Provider Demographics
NPI:1558337147
Name:JOHNSON, CAMILLE ELISE (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:ELISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:ELISE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:15301 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2952
Mailing Address - Country:US
Mailing Address - Phone:586-776-5677
Mailing Address - Fax:586-279-3467
Practice Address - Street 1:15301 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2952
Practice Address - Country:US
Practice Address - Phone:586-776-5677
Practice Address - Fax:586-279-3467
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061672207R00000X, 207QG0300X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4706904Medicaid
MI1108235612OtherBCN
MI1108235612OtherBC
MI1108235612OtherBCN
MIG75561Medicare UPIN