Provider Demographics
NPI:1760531628
Name:CHARLES JOHNSON DPM
Entity Type:Organization
Organization Name:CHARLES JOHNSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-862-5800
Mailing Address - Street 1:10244 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1904
Mailing Address - Country:US
Mailing Address - Phone:313-862-5800
Mailing Address - Fax:313-862-2865
Practice Address - Street 1:10244 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1904
Practice Address - Country:US
Practice Address - Phone:313-862-5800
Practice Address - Fax:313-862-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2007-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICJ001211213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4866541Medicaid
MIT34299Medicare UPIN
MI4866541Medicaid