Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 5901001391 | MI |
Y | 222Z00000X | Podiatrist | 5901001391 | MI |
NPI | 1063405348 |
---|---|
Provider Name | John David Johnson |
First Address | Lansing, MI 48912-4775 |
Second Address | Lansing, MI 48912-4775 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4135734 | (05) | MI |
T33976 | (02) |