Provider Demographics
NPI:1841282456
Name:JOHNSON, EWANAH D (MD)
Entity type:Individual
Prefix:DR
First Name:EWANAH
Middle Name:D
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 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-985-4632
Mailing Address - Fax:269-985-4535
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-983-8300
Practice Address - Fax:269-985-4535
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078873J207R00000X
MI4301091013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2325228Medicaid
MI1841282456Medicaid
MI1538397120OtherGROUP NPI
MI270381199OtherGROUP TAX ID
MI1538397120OtherGROUP NPI
OHJO4086761Medicare PIN
MIMI2051039Medicare PIN