Provider Demographics
NPI:1245327543
Name:JOHNSON, CHARLES MARVIN (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARVIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10244 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1904
Mailing Address - Country:US
Mailing Address - Phone:313-862-5800
Mailing Address - Fax:313-862-2865
Practice Address - Street 1:10244 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1904
Practice Address - Country:US
Practice Address - Phone:313-862-5800
Practice Address - Fax:313-862-2865
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001211213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICJ001211OtherLICENSE NUMBER
MI480H232610OtherBLUE CROSS
MI4866541Medicaid
MI4858250260OtherBCBSM
MI382683183OtherEIN
MI4858250260OtherBCBSM
MI5825026Medicare ID - Type Unspecified
MI382683183OtherEIN
MICJ001211OtherLICENSE NUMBER
MIP47360001Medicare PIN