Healthcare Provider Details

I. General information

NPI: 1467802645
Provider Name (Legal Business Name): CHAZ JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

IV. Provider business mailing address

PO BOX 22040
GREEN BAY WI
54305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 269-337-6019
  • Fax:
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301110587
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number70561
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: