Provider Demographics
NPI:1881689149
Name:JOHNSON, MARCIA L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:L
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 1:2854 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2129
Mailing Address - Country:US
Mailing Address - Phone:269-345-6197
Mailing Address - Fax:269-345-9734
Practice Address - Street 1:2854 S 11TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2129
Practice Address - Country:US
Practice Address - Phone:269-345-6197
Practice Address - Fax:269-345-9734
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMJ061404207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160038775OtherRAILROAD MEDICARE
MI1603903372OtherBLUE CROSS BLUE SHIELD
MI3353265Medicaid
731899OtherPHP