Healthcare Provider Details

I. General information

NPI: 1245327543
Provider Name (Legal Business Name): CHARLES MARVIN JOHNSON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10244 W 7 MILE RD
DETROIT MI
48221-1904
US

IV. Provider business mailing address

10244 W 7 MILE RD
DETROIT MI
48221-1904
US

V. Phone/Fax

Practice location:
  • Phone: 313-862-5800
  • Fax: 313-862-2865
Mailing address:
  • Phone: 313-862-5800
  • Fax: 313-862-2865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001211
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: