Healthcare Provider Details

I. General information

NPI: 1114285905
Provider Name (Legal Business Name): MICHELLE RULLAN JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WINDSOR ST
CAMBRIDGE MA
02139-3647
US

IV. Provider business mailing address

10 BEACON ST
SOMERVILLE MA
02143-4311
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-3600
  • Fax:
Mailing address:
  • Phone: 617-394-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number265139
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number265139
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number265139
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number265139
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: