Provider Demographics
NPI:1861489452
Name:JOHNSON, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
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 1:29275 NORTHWESTERN HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1044
Mailing Address - Country:US
Mailing Address - Phone:877-784-3667
Mailing Address - Fax:248-784-3743
Practice Address - Street 1:29275 NORTHWESTERN HWY
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1044
Practice Address - Country:US
Practice Address - Phone:877-784-3667
Practice Address - Fax:248-784-3743
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051837174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ26462011Medicare PIN
MIF77739Medicare UPIN