Provider Demographics
NPI:1548203185
Name:JOHNSON, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 MARY ADER AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5896
Mailing Address - Country:US
Mailing Address - Phone:843-763-4466
Mailing Address - Fax:843-614-4285
Practice Address - Street 1:3531 MARY ADER AVE STE D
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5896
Practice Address - Country:US
Practice Address - Phone:843-763-4466
Practice Address - Fax:843-614-4285
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83627207WX0107X, 207W00000X
ME016246208600000X
MEMD16246207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G62849Medicare UPIN
MEME0076Medicare ID - Type Unspecified