Provider Demographics
NPI:1548283633
Name:DR JO ANN JOHNSON, D.O., P.L.C.
Entity type:Organization
Organization Name:DR JO ANN JOHNSON, D.O., P.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-750-1763
Mailing Address - Street 1:3220 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-750-1763
Mailing Address - Fax:810-750-1786
Practice Address - Street 1:3220 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-750-1763
Practice Address - Fax:810-750-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4638359Medicaid
MIF13750Medicare UPIN
MI4638359Medicaid