Healthcare Provider Details

I. General information

NPI: 1265515977
Provider Name (Legal Business Name): BARRY DUANE JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S CARPENTER AVE
KINGSFORD MI
49802-5518
US

IV. Provider business mailing address

PO BOX 549
IRON MOUNTAIN MI
49801-0549
US

V. Phone/Fax

Practice location:
  • Phone: 906-776-5480
  • Fax: 906-228-0203
Mailing address:
  • Phone: 906-774-1313
  • Fax: 906-776-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number4301042058
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301042058
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: