Provider Demographics
NPI:1821088220
Name:JOHNSON, MELINDA E (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 MOUNTAIN RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9557
Mailing Address - Country:US
Mailing Address - Phone:616-581-3015
Mailing Address - Fax:
Practice Address - Street 1:5039 MOUNTAIN RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9557
Practice Address - Country:US
Practice Address - Phone:616-581-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070028207V00000X
MIMJ070028174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4319428Medicaid
MI4319428Medicaid
MIH42352Medicare UPIN