Healthcare Provider Details

I. General information

NPI: 1760531628
Provider Name (Legal Business Name): CHARLES JOHNSON DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/22/2007
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 Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberCJ001211
License Number StateMI

VIII. Authorized Official

Name: CHARLES JOHNSON
Title or Position: DPM
Credential: DPM
Phone: 313-862-5800