Provider Demographics
NPI:1598726606
Name:JOHNSON, MICHELLE JEAN JACQUES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:JEAN JACQUES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:489 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4934
Mailing Address - Country:US
Mailing Address - Phone:617-325-6550
Mailing Address - Fax:617-325-6550
Practice Address - Street 1:1125 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2178
Practice Address - Country:US
Practice Address - Phone:617-427-1000
Practice Address - Fax:617-989-3006
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA153786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA37846Medicare PIN
MAI20199Medicare UPIN