Provider Demographics
NPI:1770877151
Name:JOHNSON, MICHAEL SHANE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13600 PRAIRIE VIEW LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5917
Mailing Address - Country:US
Mailing Address - Phone:888-330-7831
Mailing Address - Fax:
Practice Address - Street 1:13600 PRAIRIE VIEW LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-5917
Practice Address - Country:US
Practice Address - Phone:888-330-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30380208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice