Healthcare Provider Details

I. General information

NPI: 1497966378
Provider Name (Legal Business Name): VIVIAN JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5104 BURNS ST
DETROIT MI
48213-5914
US

IV. Provider business mailing address

5104 BURNS ST
DETROIT MI
48213-5914
US

V. Phone/Fax

Practice location:
  • Phone: 313-350-6565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301406538
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4301406538
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: