Provider Demographics
NPI:1265517155
Name:JOHNSON, RANDALL M (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 US HIGHWAY 41 E
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-9606
Mailing Address - Country:US
Mailing Address - Phone:906-315-2607
Mailing Address - Fax:906-475-9312
Practice Address - Street 1:184 US HIGHWAY 41 E
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-9606
Practice Address - Country:US
Practice Address - Phone:906-315-2607
Practice Address - Fax:906-475-9312
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRJ0408422083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1862351Medicaid
MI2671990Medicaid
MI5100662Medicaid
MI3903600261OtherBCBS OF MI PROVIDER ID
MI0521038OtherBCC PROVIDER ID
MI0521038OtherBCC PROVIDER ID
MIF10132Medicare UPIN