Provider Demographics
NPI:1821088220
Name:JOHNSON, MELINDA E (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE
Practice Address - Street 2:SUITE 304
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2556
Practice Address - Country:US
Practice Address - Phone:616-391-2967
Practice Address - Fax:616-391-2683
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMJ070028174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4319428Medicaid
MI4319428Medicaid
MIH42352Medicare UPIN