Provider Demographics
NPI:1972768232
Name:JOHNSON, DERICK MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DERICK
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3299 N WELLNESS DR
Mailing Address - Street 2:BLDG C, #150
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7269
Mailing Address - Country:US
Mailing Address - Phone:616-738-3884
Mailing Address - Fax:616-738-4432
Practice Address - Street 1:3299 N WELLNESS DR
Practice Address - Street 2:BLDG C, #150
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7269
Practice Address - Country:US
Practice Address - Phone:616-738-3884
Practice Address - Fax:616-738-4432
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.001489390200000X
VA0102202412207X00000X
MIL1206639207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102202412OtherLICENSE