Provider Demographics
NPI:1568441491
Name:JOHNSON, VALERIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15500 LUNDY PKWY
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2778
Mailing Address - Country:US
Mailing Address - Phone:313-586-5011
Mailing Address - Fax:313-792-7134
Practice Address - Street 1:7330 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1538
Practice Address - Country:US
Practice Address - Phone:734-454-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVJ053315207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI444718810Medicaid
MIN56290003Medicare ID - Type Unspecified
F53701Medicare UPIN