Provider Demographics
NPI:1609920032
Name:JOHNSON, EDWARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1085 S LINDEN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3421
Mailing Address - Country:US
Mailing Address - Phone:810-732-3240
Mailing Address - Fax:810-230-0280
Practice Address - Street 1:ONE HURLEY PLAZA
Practice Address - Street 2:FAMILY AMBULATORY CLINIC
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-257-9191
Practice Address - Fax:810-257-9187
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4113290Medicaid
MIOB56031OtherBLUE CROSS BLUE SHIELD MI
G53889Medicare UPIN
MIB56031063Medicare ID - Type UnspecifiedMEDICARE ID