Provider Demographics
NPI:1982799011
Name:JOHNSON, DAVID K (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2175 COOLIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1379
Mailing Address - Country:US
Mailing Address - Phone:517-324-3705
Mailing Address - Fax:517-324-4589
Practice Address - Street 1:1625 RAMBLEWOOD DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6367
Practice Address - Country:US
Practice Address - Phone:517-324-3705
Practice Address - Fax:517-324-4589
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDJ0366892088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101312174Medicaid
340009577OtherRAILROAD MEDICARE
DR330319OtherMCARE
1000638OtherMCLAREN
200000002171OtherPHYSICIAN HEALTH PLAN
340C376010OtherBLUE CROSS BLUE SHIELD
4496865OtherAETNA
MI101312174Medicaid
200000002171OtherPHYSICIAN HEALTH PLAN