Provider Demographics
NPI:1861404931
Name:JOHNSON, MICHAEL A (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3546
Mailing Address - Country:US
Mailing Address - Phone:765-962-9900
Mailing Address - Fax:
Practice Address - Street 1:2990 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3546
Practice Address - Country:US
Practice Address - Phone:765-962-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001155A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100257280AMedicaid
IN100257280AMedicaid
INJO905250Medicare ID - Type Unspecified