Provider Demographics
NPI:1831204122
Name:JOHNSON, MICHELE (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
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:PO BOX 71
Mailing Address - Street 2:C/O KDC MANAGEMENT
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-0071
Mailing Address - Country:US
Mailing Address - Phone:978-657-5866
Mailing Address - Fax:978-657-5877
Practice Address - Street 1:60 EAST ST
Practice Address - Street 2:SUITE 3300
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4500
Practice Address - Country:US
Practice Address - Phone:978-685-3440
Practice Address - Fax:978-657-5877
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH01Y005533MA01OtherANTHEM
NH30008466OtherMEDICAID NH GROUP
MA708116OtherTUFTS INDIV.NUMBER
MA6967OtherFALLON
MAD13217OtherBC/BS INDIVIDUAL #
MANEIGHBORHOOD HEALTHOther1801562
MA98207101OtherNETWORK INDIV NUMBER
MA0173096Medicaid
MA1309662OtherUNITED HEALTHCARE
NH30205174OtherMEDICAID OF NH INDIV
MA13307OtherHARVARD PILGRIM
MA51762OtherFALLON GROUP NUMBER
MA978403OtherNETWORK GROUP NUMBER
MA611003OtherTUFTS GROUP NUMBER
MAM17489OtherBC/BS GROUP NUMBER
MA9787143Medicaid
MAM17489OtherBC/BS GROUP NUMBER
MAD13217OtherBC/BS INDIVIDUAL #
MA13307OtherHARVARD PILGRIM
MA611003OtherTUFTS GROUP NUMBER