Healthcare Provider Details

I. General information

NPI: 1457514549
Provider Name (Legal Business Name): MICHAEL GEORGE JOHNSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

IV. Provider business mailing address

57 S MAIN ST
MIDDLETOWN CT
06457-3606
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6293
  • Fax:
Mailing address:
  • Phone: 860-638-0050
  • Fax: 860-346-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number052808
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number052808
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: