Healthcare Provider Details

I. General information

NPI: 1558920330
Provider Name (Legal Business Name): MATTHEW LEE JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W SAGINAW ST
LANSING MI
48915-1927
US

IV. Provider business mailing address

516 NUGGETT DR
LANSING MI
48917-2411
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-7700
  • Fax:
Mailing address:
  • Phone: 740-708-3871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5151013598
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101025738
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: