Provider Demographics
NPI:1902895584
Name:JOHNSON, MICHAEL SHAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:SHAWN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1710 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3357
Mailing Address - Country:US
Mailing Address - Phone:304-256-4100
Mailing Address - Fax:
Practice Address - Street 1:1710 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3357
Practice Address - Country:US
Practice Address - Phone:304-256-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1404207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000025499OtherBC
WV0040103000Medicaid
WV000025499OtherBC
F74106Medicare UPIN
WVJO0789964Medicare PIN
WV0789963Medicare ID - Type Unspecified