Provider Demographics
NPI:1952539603
Name:JOHNSON, KORY JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:KORY
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-464-6170
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135656207XS0114X
MI5101018118207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD14869OtherMEDICARE GROUP PTAN
MIOD14869OtherMEDICARE GROUP PTAN