Provider Demographics
NPI:1639341076
Name:JOHNSON, WALLACE EMANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:EMANUEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 LEEWARD CT
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5053
Mailing Address - Country:US
Mailing Address - Phone:313-393-2741
Mailing Address - Fax:
Practice Address - Street 1:273 LEEWARD CT
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-5053
Practice Address - Country:US
Practice Address - Phone:313-393-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027092207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery