Healthcare Provider Details

I. General information

NPI: 1548283633
Provider Name (Legal Business Name): DR JO ANN JOHNSON, D.O., P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 SILVER LAKE RD
FENTON MI
48430
US

IV. Provider business mailing address

3220 SILVER LAKE RD
FENTON MI
48430
US

V. Phone/Fax

Practice location:
  • Phone: 810-750-1763
  • Fax: 810-750-1786
Mailing address:
  • Phone: 810-750-1763
  • Fax: 810-750-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010026
License Number StateMI

VIII. Authorized Official

Name: JO ANN JOHNSON
Title or Position: PRESIDENT OWNER
Credential: D.O.
Phone: 810-750-1763