Provider Demographics
NPI:1467682971
Name:JOHNSON, KIMBERLY SUE (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT#9516
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-7919
Mailing Address - Country:US
Mailing Address - Phone:231-935-0497
Mailing Address - Fax:
Practice Address - Street 1:1105 SIXTH STREET
Practice Address - Street 2:SUITE#100
Practice Address - City:49684 TRAVERSE CITY, MI (GRAND TRAVERSE)
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010948692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology