Healthcare Provider Details

I. General information

NPI: 1306523824
Provider Name (Legal Business Name): DEREK JOHNSON RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MACK AVE
DETROIT MI
48201-2136
US

IV. Provider business mailing address

400 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-448-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86080897
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: