Provider Demographics
NPI:1790992113
Name:MAO, JOHNNY C (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:C
Last Name:MAO
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 1:555 BRUSH ST APT 2008
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4355
Mailing Address - Country:US
Mailing Address - Phone:313-377-2373
Mailing Address - Fax:
Practice Address - Street 1:540 E CANFIELD ST
Practice Address - Street 2:5E-UHC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1928
Practice Address - Country:US
Practice Address - Phone:313-577-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085941207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology