Provider Demographics
NPI:1891248134
Name:JOHNSON, BENJAMIN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
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 1:75 BARCLAY CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5821
Mailing Address - Country:US
Mailing Address - Phone:248-853-9177
Mailing Address - Fax:248-853-7258
Practice Address - Street 1:75 BARCLAY CIR STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5821
Practice Address - Country:US
Practice Address - Phone:248-853-9177
Practice Address - Fax:248-853-7258
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301119219208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery