Healthcare Provider Details

I. General information

NPI: 1477398022
Provider Name (Legal Business Name): MATTHEW DAVID JOHNSON PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

50451 OREGON AVE
NOVI MI
48374-1477
US

V. Phone/Fax

Practice location:
  • Phone: 313-989-9444
  • Fax:
Mailing address:
  • Phone: 734-812-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: