Provider Demographics
NPI:1942396551
Name:JOHNSON, MICHELE D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:D
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:PO BOX 950171
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:40295-0171
Mailing Address - Country:US
Mailing Address - Phone:502-891-8700
Mailing Address - Fax:502-891-8709
Practice Address - Street 1:3900 KRESGE WAY #30
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-891-8700
Practice Address - Fax:502-891-8709
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33512207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64036510Medicaid
KY64036510Medicaid
KY0567210Medicare ID - Type Unspecified