Healthcare Provider Details

I. General information

NPI: 1083752802
Provider Name (Legal Business Name): GARY KEITH JOHNSON M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S SAGINAW ST
FLINT MI
48502-1525
US

IV. Provider business mailing address

630 S SAGINAW ST
FLINT MI
48502-1525
US

V. Phone/Fax

Practice location:
  • Phone: 810-257-3155
  • Fax: 810-257-3147
Mailing address:
  • Phone: 810-257-3155
  • Fax: 810-257-3147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301049794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: