Provider Demographics
NPI:1518907138
Name:JOHNSON, SHERYL L (MD)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 9541
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-8016
Mailing Address - Country:US
Mailing Address - Phone:800-475-6236
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2514
Practice Address - Country:US
Practice Address - Phone:616-267-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131146207ZP0213X
VA01012311502084P0800X
MI4301502126207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1518907138Medicaid
VAH76354Medicare UPIN
VA006567U92Medicare PIN